LIBRARY OF CONGRESS. 



7? 



i^. 



f:4^ 



\!P-^'f 



@]^^.. ,...: Sijp|ri# lu 



Shelfi 



UNITED STATES OF AMERICA. 



Nekyous Diseases 



AND THEIR 



DIAGNOSIS 



A TREATISE UPON THE PHENOMENA PRODUCED BY 
DISEASES OF THE NERVOUS SYSTEM, WITH 
ESPECIAL REFERENCE TO THE RECOG- 
NITION OF THEIR CAUSES. 



^y^/ BY 

HfC. WOOD, M.D., LL.D., 



MEMBER OF THE NATIONAL ACADEMY OF SCIENCE. 



(Jv4a1u 



1^. 



i 




PHILADELPHIA: 

J. B. LIPPINCOTT COMPANY. 

1887. 



a 



e 



^1 



Copyright, 1887, by H. C. Wood. 




TO 



Surgeon JOHN S. BILLINGS, U.S.A., 

FACILE PEINCEPS OF MEDICAL BIBLIOGEAPHERS, 



THIS BOOK 



IS RESPECTFULLY DEDICATED, AS AN ACKNOWLEDGMENT THAT WITHOUT 
HIS SELF-SACRIFICING LABORS IT WOULD NOT HAYE BEEN POS- 
SIBLE TO ITS AUTHOR, AND AS A TOKEN OF THE 
WARMEST PERSONAL ATTACHMENT 
AND ESTEEM. 



PREFACE. 



By way of apology for again trespassing upon the patience 
of the profession, the author of the present volume would say 
that the work is founded upon a hospital service continuous, 
except for one short period, for twenty-iBve years. Of this 
service fifteen years were spent in the medical wards of very 
large military or civil general hospitals, while for the last ten 
years nervous wards in the Philadelphia Hospital, aggregating 
one hundred and twenty-five beds, and the nervous clinic of 
the Hospital of the University of Pennsylvania, comprising over 
five hundred new cases annually, have been under the charge 
of the author. In his youthful days he also served as resident 
physician in an insane asylum, and more recently he has been 
connected with several such institutions as a consultant. 

Notwithstanding this experience, the author would not have 
ventured to add a new book to the already long list of treatises 
upon nervous diseases had he not been strongly urged thereto 
by some of his former pupils, who insisted that the method of 
teaching which had been gradually evolved in the weekly 
clinics of the University Hospital was different from that com- 
monly in vogue, and if followed out would give freshness to an 
old subject. 

The defects of the work are perhaps better known to its 
author than they will be to any of its readers or critics, but 
they are not the result of lack of honest effort, and if the kindly 
judgment of brother practitioners should by any chance bring 
the work to another edition, whatever criticism it may receive 



6 PREFACE. 

will be thankfully accepted, thoroughly weighed, and duly acted 
upon. 

In conclusion, the author desires to acknowledge his indebted- 
ness to Dr. George E. De Schweinitz for much assistance rendered 
in various ways and places, but especially in the anatomical por- 
tion of the book, in the chapter on Eye Symptoms, and in pre- 
paring the index. Thanks are also due Mr. Joseph McCreery 
for his extraordinarily intelligent and suggestive reading of the 
proofs. 

University of Pennsylvania, 
January 1, 1887. 



CONTENTS. 



INTRODUCTION. pages 

General Discussion of Disease, and of Neurasthenia .... 17-22 

CHAPTER I. 

PARALYSIS. 

Detection of Paralysis. 

Functional Palsies, including Reflex, Assumed, and Hysterical Pal- 
sies. 

Organic Palsies. OeneQ^al Palsies, including Hysterical, Alcoholic, In- 
termittent, Cerebral, Pons, Bulbar, and Lenticular Palsies. Hemi- 
plegia^ including Spinal, Cerebral, Corpus Striatum, Thalamus 
Optici, Pons, Facial, Crossed Palsy. Paraplegia, Functional Para- 
plegia, including Reflex, Renal, and Hysterical Paraplegia. Organic 
Paraplegia, divided into Abrupt, Subacute, and Chronic Paraplegia. 
Abrupt Paraplegia, including Apoplexy into the cord and into its 
membranes, Haematomyelitis. Subacute Paraplegia, including Pain- 
ful Paraplegia, Ascending Paralysis, Acute Central Myelitis, Mul- 
tiple Neuritis. Transverse Myelitis, Cervical Pachymeningitis. 
Chronic Paraplegia, including Chronic Myelitis, Spasmodic Tabes, 
Amyotrophic Lateral Sclerosis, Multiple Spinal Sclerosis. Mono- 
plegia^ including Hysterical Monoplegia, Double Monoplegia, Cere- 
bral Monoplegia, both Abrupt and Progressive, Peripheral Mono- 
plegia from pressure, as in Crutch Palsy, from disease of the nerves, 
and from poison. Multiple Palsy ^ divided into Cerebral, including 
Syphilitic, Sclerotic, and Spastic Infantile Paralysis, and Periph- 
eral, including Diphtheritic Paralysis, Poliomyelitis, Local Mus- 
cular Atrophies, Joint Atrophies, Toxaemic Peripheral Palsies, Pro- 
gressive Muscular Atrophy, and Pseudo-Hypertrophic Paralysis. 
Local Paralysis^ including Oculo-Motor, Trochlear, Trigeminus, 
Abducens, Facial, Glosso-Pharyngeal, Spinal Accessory, Long Tho- 
racic, Sub-Scapular, Supra-Scapular, and Circumflex, Anterior Tho- 
racic, Musculo-Cutaneous, Musculo-Spiral, Median, Ulnar, Spinal, 
Ilio-Hypogastric, Ilio-Inguinal, Intercostal, Anterior Crural, Ob- 
turator, Superior and Inferior Gluteal, Sciatic, External Popliteal, 

Internal Popliteal, and Post-Tibial Nerves 23-95 

7 



8 CONTENTS. 

CHAPTER II. 

MOTOR EXCITEMENTS. 

PAGES 

General Discussion, including definitions of Convulsions, Spasms, Choreic 
Movements, Tremors, Automatic Movements, and Contractures. 

Convulsions, including Epileptiform, Hysteroidal, and Tetanic. Epi- 
leptiform Convulsions, including Idiopathic Epilepsy in its various 
forms, Reflex Epilepsy, Convulsions of Childhood, Pleuritic Epi- 
lepsy, Cardiac Epilepsy, Organic Epilepsy, Convulsions from Cere- 
bral Hemorrhage, Epilepsy in General Paralysis, Toxaemic Epilepsy, 
and Uraemia. Hysteroidal Convulsion, including Minor Hysteria. 
Tetanic Convulsions, including Hysteria, Tetanus, Trismus Neona- 
torum, and Tetany. Local Spasms, Spasms of the Muscles of Or- 
ganic Life, including (Esophageal, Rectal, and Urethral Spasm, 
Vomiting, Nervous Cough, Phantom Tumor. Spasms of Volun- 
tary Muscles, including Laryngismus Stridulus, Occupation Neuro- 
ses, Cortical, Hysterical, Inflammatory, and apparently Causeless 
Spasms, also Facial Nerve Spasm in its various forms, and Spinal 
Accessory Spasms. 

Tremors, Senile, Toxic, Paralysis Agitans, Multiple Cerebro-Spinal 
Sclerosis. 

Chorea. General Chorea, including St. Vitus's Dance, Reflex Chorea, 
Chorea of Pregnancy, Hysterical Chorea, Rhythmical Chorea. 
Local Chorea, including Paralytic Chorea, Chorea of Stumps, Habit 
Choreas. 

Contractures, including Cerebral, Infantile Paralysis, Meningeal, 
Neuritis, Hysterical, Lateral Sclerosis, and Thomsen's Disease. 

Automatic Movements during Chorea Major, Psychical Automatism 

and Miryachit 96-179 

CHAPTER III. 

REFLEXES. 

General Discussion, dividing Reflexes into Superficial and Deep. 
Superficial Reflexes, including Plantar, Gluteal, Cremaster, Epi- 
gastric, Erector-Spinal, Scapular, Palmar, and Cranial. 
Deep Reflexes, including Knee-Jerk and Ankle-Clonus . . 180-193 

CHAPTER IV. 

disturbances of equilibration. 

General Discussion. 

Disturbance of Co-Ordination ; Loss of Co-ordination, including 

Locomotor Ataxia, General Paralysis, Multiple Neuritis. 
TiTUBATiON, including Cerebellar Aff'ections and Rotatory Movements. 
Vertigo, including Organic, Cardiac, Epileptic, Hysterical, Peripheral, 

Special Sense, Toxaemic, and Essential Vertigo .... 194-212 



CONTENTS. 9 

CHAPTER V. 

TROPHIC LESIONS. 

PAGES 

General Discussion, dividing lesions into Acute Destructive and Chronic 

Lesions. 
Acute Destructive Lesions, including Decubitus, Perforating Ulcer, 

and Acute Symmetrical Gangrene. 
Chronic Lesions, including those of Skin, Bone, Joints, Muscles, and 

Nervous System, as seen in various diseases and poisonings ; also 

Glosso-Labial Palsy and Progressive Facial Hemiatrophy . . 213-251 

CHAPTEE VI. 

SENSORY PARALYSIS. 

General Discussion, including Modes and Instruments of Testing. 

Visceral Anesthesias, including Throat, Eectum, Vagina, and Blad- 
der. 

Cutaneous Anesthesia, Hysterical, Psychic, Organic, and Toxasmic, 
including Metallotherapy. 

Organic Anesthesias, including General Anaesthesia, Hemiansesthesia, 
Crossed Paralysis, and the Lesions which produce them. 

Organic Paranesthesia. 

Organic Monoanesthesia. 

Local Anesthesias, including discussion of various nerve-distribu- 
tions . . . 252-280 

CHAPTEE VII. 

exaltations of sensibility. 

General Discussion. 

Hyperesthesia. Hysterical Hypersesthesia^ including Genitalia, 
Breasts, Joints, and Back. Organic Hyper sesthesias. 

Paresthesias. 

Pain, Neuralgic Temperament. Pains in the Extremities^ including 
Gouty, Neuritic, Metallic, Spinal, Neuralgic. Trunkal Pains, Ke- 
flex, Rheumatic, Toxsemic Pains, Girdle-Pains, also Rectal, Gastric, 
Intestinal, Genital, Laryngeal, and Cardiac Crises. Head-Pains, 
Toxaemic Headache, including Rheumatic, Lithaemic, Uraemic, 
Alcoholic, Caffeinic, Gastric, Diabetic, Cardiac, and Pulmonic. 
Sympathetic Headaches, including Eye-Strain and Nasal Headaches. 
Nervous Headaches, including Anaemic, Congestive, and Hysterical 
Headaches, and Migraine. Face-Pains, Neuralgic, Reflex, Neuritic, 
Prosopalgic 281-316 



10 CONTENTS. 



CHAPTER VIII. 

DISTUEBANCES OF THE SPECIAL SENSES. 

PAGES 

Hearing, including Nervous Deafness and Hypersesthesia. 

Sight. Movements of the Eye^ including Strabismus, Secondary and 
Primary Deviation, Simple and Crossed Diplopia, False Projection 
of the Visual Field, Paralysis of Oculo-Motor, Trochlear, and Ab- 
ducens Nerves, Ophthalmoplegia Interna and Externa, Associated 
Ocular Paralysis, Conjugated Deviation of Head and Eyes. Internal 
Ocular Conditions^ including Choked Disk, Atrophy of the Disk, 
Irregularities, Keflexes, and other Derangements of the Pupil, 
Amaurosis. Vision^ including Method of Testing, Functional, Or- 
ganic, and Toxsemic, Hemianopsia in its various forms. 

Taste, including Hypersesthesia, Anaesthesia, and Hallucinations. 

Smell, including Hyperaesthesia, Anaesthesia, and Hallucinations . 317-356 

CHAPTER IX. 

disorders of memory and consciousness. 

General Discussion. 

"Word-Memory, including Aphonia, Aphaemia, and Aphasia in all its 
forms ; also Word-Blindness and Word-Deafness. 

General Memory, including Exaltation and Failure of Memory. 

Correlated Disorders of Memory and Consciousness, including 
Loss of Personal Identity, Double Personality, and Double Con- 
sciousness, or Periodic Amnesia, also Double Perception . . 357-376 

CHAPTER X. 

disorders of consciousness. 

General Discussion. 

Sudden Loss of Consciousness, including Hysterical, Epileptic, and 
Syncopal Loss of Consciousness, Sunstroke in both its forms. Apo- 
plexy and Unconsciousness from Indirect Causes, such as Alcohol, 
Opium, and Uraemic and other poisons, and from Malaria, Emo- 
tional Excitement, and Acute Systemic Disorders. 

Sleep, its Disorders and Accidents. Abnormal Wakefulness. 

Morbid Sleep, including Coma-Yigil and other affections of Sleep in 
acute fevers, Nelavan, Trance or Lethargy, Catalepsy, Lucid Leth- 
argy, Epileptic Sleep, Reflex Unconsciousness, Narcolepsy, Hysteri- 
cal Sleep, Hypnotism, Sleep during Insanity, Toxaemic Sleep, such 
as Uraemic and Diabetic Coma. 

Organic Stupor, or Coma. Non-Specific Stuporous Affections with Head- 
ache^ including Brain-Tumor, Meningitis, Pachymeningitis Haemor- 
rhagica. Specific Stuporous Affections^ including Fulminating and 
gradually-developed Syphilitic Coma. Organic Stuporous Affections 
without Headache^ including Polioencephalitis. 

Accidents of Sleep, including Sense- Shock, Night-Palsy, Somnam- 
bulism, Night-Terrors 377-419 



CONTENTS. 11 

CHAPTER XI. 

DISTURBANCES OF INTELLECTION. 

PAGES 

General Discussion, including Abulia, Hyperbulia, Increase and Failure 
of the Mental Powers, Incoherence, Character, Hallucinations and 
Illusions, Delusions, Imperative Conceptions, Morbid Impulses and 
Morbid Desires, Nymphomania, Erotomania, Delirium in acute 
constitutional diseases, Classification of Insanity. 

Complicating Insanities, including Acute and Chronic Meningitis, 
Acute and Chronic Periencephalitis, and Cerebral Sclerosis. 

Diathetic Insanities, including Gouty, Epileptic, Hysterical, Syphi- 
litic, Alcoholic (Delirium Tremens and Chronic Insanity). 

Pure Insanities. Complete Insanities. Complete Non-Periodic Insani- 
ties, including Mania, Acute and Chronic ; Melancholia, Acute and 
Chronic; Katatonia; states of Mental Deterioration, such as Organic 
Dementias, Hebephrenia, Senile Dementia, Dementia of Cerebral 
Shock, Primary Confusional Insanity, Stuporous Insanity, Terminal 
Dementia ; Periodic Insanities, such as Periodic Mania, Periodic 
Melancholia, Circular Insanity. Incomplete Insanities^ including 
Monomania and Mania of Character 420-492 

INDEX 493-501 



INTRODUCTION. 



The primary meaniDg of the word ^^ disease'^ is pain, uneasi- 
ness, or distress. In its derived or secondary significance it is 
defined by Webster as a deviation from health in function or in 
structure. In modern medicine the term has come to have a still 
more restricted technical meaning, being used to signify a simple or 
complex pathological process which is complete in itself. Thus, a 
simple enteritis is a disease ; but the enteritis of typhoid fever is a 
part of a complex pathological process which constitutes the dis- 
ease known as typhoid fever. When the term disease is, as it 
ought to be, used in this narrow sense, the diseases of the nervous 
system are far fewer than the number usually assigned by standard 
authorities upon the subject. 

The symptoms produced by pathological processes or diseases 
depend upon their seat ; and whilst it may be necessary to con- 
sider acute inflammation of the brain as a diflferent disease from 
an acute inflammation of the spinal cord, the various parts of 
the nervous system are so interwoven that we cannot draw lines 
between the various affections. Thus, a chronic poliomyelitis 
affecting certain regions of the medulla oblongata gives rise to 
the so-called glosso-labial paralysis, but when affecting the lower 
portions of the spinal cord it produces progressive muscular 
atrophy. Not rarely, however, both regions are simultaneously 
attacked, when, in deference to an unscientific and misleading 
nomenclature, the patient is said to suffer from two distinct dis- 
eases. 

Partly led by considerations such as those just stated, and 
partly as the result of the exigencies of clinical teaching, in the 
course of years I have gradually adopted a method of instructing 
students which has seemed to me more in accord with the every- 
day needs of the medical practitioner, and more apt to lead to a 
practical understanding of diseases of the nervous system, than 
is that adopted in the ordinary treatises upon the subject. When 

2 17 



18 INTRODUCTION. 

a case offers itself for examination, the physician raust needs 
travel from the symptoms back to the lesion, and not from the 
lesion to the symptoms. He does not say, this man has a clot in 
the brain, therefore he has hemiplegia, but he begins with the 
paralysis, and passes from it by the process of induction to the 
lesion. Hitherto the authors of text-books have travelled from 
the lesion to the symptoms. The present treatise is an attempt 
to follow the route which the practitioner must pass over daily. 

Before entering upon the discussion of the individual symp- 
toms produced by diseases of the nervous system it seems to me 
necessary to consider the subject of neurasthenia^ or nervous weak- 
ness, because the symptoms of this state are so indefinite and fugi- 
tive that it is almost impossible to marshal them into order. 

Much effort has of recent time been wasted in attempting to 
make of neurasthenia a disease. It is a bodily condition which 
is frequently associated with various chronic disorders, and not 
rarely coexists with perverted functional activity of the nervous 
centres, which perverted nerve-functions may, however, exist in- 
dependently of any perceptible neurasthenia, and are not simply 
the outcomes of the neurasthenia. It is an hal)itual foundation 
for hysteria, chorea, insanity, and various nervous diseases, but 
may exist without the superaddition of any of them. 

The onset of neurasthenia is always gradual, although at times 
the condition appears to develop with great suddenness. Under 
these circumstances, however, the explosion has been preceded by 
a long train of more or less overlooked phenomena: thus, a gen- 
tleman who had long suffered from the premonitory symptoms of 
neurasthenia was one day seized with violent vertigo, accompanied 
by such prostration of strength that he had to be taken home from 
the street in a carriage. The symptoms vary greatly according 
to the portion of the nervous system which is especially affected, 
and also to some extent according to the etiology of the attack. 
Nervous exhaustion may in the beginning affect the whole of the 
nervous system, or it may be at first purely local and coexist with 
general nervous strength. Many cases of spermatorrhoea are in- 
stances of the local form of neurasthenia, the sexual centres being 
primarily affected; but as in these cases, sooner or later, the 
whole of the nervous system becomes implicated, so in other 
forms of the disorder the exhaustion, at first local, finally, if 



INTKODUCTION. 19 

neglected, implicates the whole organism. There are not rarely 
cases of brain-exhaustion in which the symptoms are at first 
purely local. Almost always the cause of a local neurasthenia is 
excessive use of the part : thus, cerebral asthenia is usually the 
result of mental overwork, sexual asthenia of sexual excesses, 
etc. When to the intellectual fatigue are added the depressing 
eifects of excessive anxiety or allied emotions, the symptoms 
from the first are more general. The exhaustion may affect 
chiefly a single function of the brain. As an instance may be 
cited the case of a postal clerk under my care, who has been ac- 
customed to distribute five to eight thousand letters every day 
from a general mass into three hundred pigeon-holes, representing 
as many post-office districts, scattered over a large territory. As 
soon as the address is read there must be an instantaneous auto- 
matic recognition of the district to which the letter goes. It 
is at this place that, in the case now under consideration, the 
symptoms manifest themselves. Reading the address fails to 
produce immediate recognition of the locality to which the letter 
is to be assigned. Asked in what district such a post-office is, 
the clerk answers instantly, but seeing the address himself he 
hesitates, and sometimes balks so that he can distribute only about 
one-third as many letters as when in health. As in most cases of 
local nerve-exhaustion, in this patient some evidences of general 
implication exist, there being decided disturbance of the sexual 
organs. 

A form of local neurasthenia which is frequently associated 
with brain-exhaustion is writer^s cramp. I have repeatedly seen 
it come on as the herald of a general break-down ; but under 
such circumstances the symptoms have usually not been those 
of typical writer's cramp : there have been not so much marked 
spasms as loss of power and distress in the arm on attempting 
to write. 

In pure brain-exhaustion loss of the disposition to work is 
usually the first symptom, the sufferer finding that it constantly 
requires a more and more painful effort of the will to perform the 
allotted task. The basis of this difficulty is largely loss of the 
power of fixing the attention, and this by and by is accompanied 
by weakness of the memory. Disturbances of sleep are fre- 
quent. Various abnormal sensations in the head are complained 



20 INTRODUCTION. 

of. In most cases there is not absolute headache, but a feeling of 
weight or fulness, or an indescribable distress, usually aggravated 
by mental eflPort. 

It is true that in some cases of very dangerous brain-tire cere- 
bration is performed with extraordinary vigor and ease; the 
power of work is for the time markedly increased, and even the 
quality of the product may be raised ; the patient may glory in a 
wild intellectual exaltation, a sense of mental power, with an 
almost uncontrollable brain-activity. It is probable, however, 
that these cases are not instances of pure neurasthenia, but that 
there is an active congestion of the cortical gray matter. It is 
certain that they are very prone to end in serious organic brain- 
trouble. In some cases of cerebral asthenia there are disturb- 
ances of the special senses, tinnitus aurium, flashes of light, and 
even the seeing of visions. Under these circumstances it is again 
probable that active congestion of the affected centres exists. 

Severe cerebral neurasthenia may be associated with good 
spirits, but usually there is marked depression, and this perver- 
sion of function may finally go on to decided melancholy. The 
will-power, like all the other functional activities of the brain, 
is prone to be weakened ; morbid fears may finally develop ; 
and at last that which was at the beginning a simple brain-ex- 
haustion may end in hypochondriasis or insanity. According to 
my own experience, such ending is, however, very rare, unless 
there is an inherited tendency to insanity. 

Disturbances of sensation are common in neurasthenia, these 
disturbances taking the form in many instances of itchings or 
formications or similar minor ills. Neuralgia is often severe and 
its attacks frequent, but I am convinced that something more 
than simple nervous exhaustion is responsible for its production. 
I believe that there is a neuralgic diathesis or temperament which 
is often associated with neurasthenia, but may exist without it, 
and which probably has, at least in many cases, relations to a 
gouty ancestry. When such temperament exists, the neuralgic 
attacks are greatly aggravated by the coming on of neurasthenia. 
Hypersesthesia and anaesthesia mark the line where simple neur- 
asthenia passes into hysteria. The same also is true of the 
peculiar tenderness over the spinal processes of the vertebrae, 
which is especially frequent in women, and is the chief symptom 



INTRODUCTION. 21 

of the so-called spinal irritation or spinal ansemia, — an affection 
which I believe to be a form of neurasthenia allied to hysteria. 

In neurasthenia disturbances of the sexual organs are very 
common; in women great pain on menstruation, ovarian irrita- 
tion, the so-called irritable uterus of Hodge, are closely connected 
with general nerve-weakness. In not a small proportion of the 
cases of uterine disorders which are locally treated, I believe the 
local disease is largely the expression of the general condition. 
It is well known that masturbation and sexual excess in the 
male may produce an exhaustion of the nerve-centres especially 
implicated, and also a general nervous exhaustion. This is the 
common history of spermatorrhoea. It is no less true that a gen- 
eral neurasthenia may produce a local weakness of the sexual 
centres, with symptoms at least resembling those of spermator- 
rhoea, — namely, great irritability of the sexual organs, with a 
practical impotence due to immediate seminal discharge whenever 
coition is attempted. I have certainly seen this condition result 
from excessive intellectual labor when there has been no sexual 
excess, and at a time when the muscular strength was still good. 
Such cases may, perhaps, be distinguished by the fact that unpro- 
voked emissions are not nearly so apt to occur as in true sperma- 
torrhoea. 

In cases of nervous exhaustion the efforts of the diagnostician 
are chiefly directed to determining the cause of the exhaustion. 
In a very considerable proportion of cases which have been sent 
to me as suffering from simple neurasthenia, chronic malaria, 
chronic diarrhoea, Bright's disease, or other serious organic affec- 
tion has existed : it is therefore essential that in every case of 
alleged neurasthenia a thorough examination be made to detect 
latent chronic disease. When no such disease can be found, the 
cause of the neurasthenia should be recognized. In rare cases it 
develops in women, without perceptible cause, at pubescence or at 
the climacteric. 

Overwork, especially overwork combined with worry, and even 
continuous emotional depression, unaided by excessive work, are 
capable of producing a pure neurasthenia. As Samuel Jackson 
was accustomed to say, in his lectures at the University of Penn- 
sylvania thirty years ago, ^^ Whenever the expenditure of nerve- 
force is greater than the daily income, physical bankruptcy sooner 



22 INTRODUCTION. 

or later results/^ It is to be remembered that the nerve-capital 
of persons differs almost as widely as does their moneyed capital. 
There are numerous families many of whose members are neur- 
asthenics from birth, — Le,, are born with less power of creating 
nervous energy than is necessary to meet the requirements of 
the ordinary duties of life. There is every grade of natural 
endowment between the most feeble person, scarcely able to pro- 
duce more nervous energy than is necessary for breathing, eating, 
and drinking, and the organism that is capable of enduring in- 
cessant toil. The development of neurasthenia is therefore not so 
much the result of a strain which is absolutely great, as of a 
strain which is excessive in its relations to the organism which has 
to bear it. I have seen not a few cases in which the neurasthenia 
has appeared to me to be an expression of premature old age. In 
such cases the rigid, atheromatous radial arteries occurring in a 
non-gouty or non-syphilitic subject have pointed to a similar ex- 
cessive ripeness of tissue throughout the body. 




DIAGNOSTIC SYMPTOMATOLOGY 



OF 



NERVOUS DISEASES. 



CHAPTER I. 

PARALYSIS. 



Paralysis. — The word paralysis may be correctly employed to 
signify loss of nerve-function, either motor or sensory. But in 
the present volume it will be used to mean loss of voluntary 
motor power^ the term anaesthesia being employed to represent 
sensory palsy. 

Paralysis may be either partial or complete : a partially para- 
lyzed muscle is capable of contracting with less than its normal 
force in response to the will ; a completely paralyzed muscle is 
incapable of voluntary movement. 

Detection of Pojralysis, — In a case of supposed paralysis it is 
necessary first to decide whether the alleged loss of power results 
from a true paralysis or is due to other cause. I have not rarely 
seen a patient suffering from an immovable joint diagnosed as 
paralytic, when the immobility was the result of the inflammation 
of the structures around the joint. Again, loss of power may be 
the result of pain arresting motion, as in a rheumatic muscle. 
Spasm may also cause loss of mobility, and sometimes a failure 
of execution supposed to be paralytic is due to loss of co-ordina- 
tion. A true paralysis is to be distinguished by the loss of the 
power of moving, either partially or entirely, together with there 
being no pain on passive or active movement, and no sense of 
resistance experienced by the physician when moving the affected 

23 



24 DIAGNOSTIC NEUROLOGY. 

part. A paralysis may of course be coincident with a local in- 
flammation which produces pain and soreness, and still more 
frequently is it associated with spasm : under these circumstances 
careful examination during both passive and active movements 
may be necessary for the detection of the underlying palsy. 

For the estimation of the degree of partial paralysis various 
instruments have been employed : of these the only one com- 
monly used is the hand-dynamometer. The power of the legs 
can usually be judged of with sufficient accuracy by noting, the 
height to w^hich the patient, when sitting in a chair, can raise the 
feet, the ability to get out of the chair, and the power of en- 
durance during standing or walking. A foot-dynamometer may 
be useful for estimating small gains of power under treatment, 
but is rarely employed. 

FUNCTIONAL PALSIES.; 

When paralysis has been found to exist, it is necessary to deter- 
mine whether it is a true organic palsy, or whether it is assumed, 
hysterical, or reflex in its nature. 

Reflex Palsies. — It is well known that paralysis in a distant 
part is in some cases closely connected with a violent nervous 
irritation, such as a wound in the nerve-trunk, stone in the kid- 
neys, etc. To such cases the name of Reflex Palsy has been 
given. There are, however, two entirely distinct classes of cases 
which have been grouped together under this name. In most of 
the recorded cases the paralysis has developed gradually, and has 
undoubtedly been the result of a secondary organic disease of the 
nerves or spinal cord. Thus, a man receives a wound in the 
hand involving a nerve, and slowly, step by step, the arm loses its 
power and becomes livid and cold. Under such circumstances 
there is undoubtedly an ascending neuritis. Or from a stone in 
the kidney a paraplegia gradually develops, the result of a sec- 
ondary myelitis. (See Subacute Paraplegia.) There are, however, 
cases, like those reported by Dr. S. Weir Mitchell (Injury of 
Nerves, Philadelphia, 1872), in which the wound of a nerve is 
followed at once by a distant palsy ; or like those in which a para- 
plegia is at once removed by the removal of an irritation, such 
as an adherent prepuce. In these cases there can be no organic 



PARALYSIS. 25 

disease of the nerve or cord, and it seems to me no more extraor- 
dinary that there should be a reflex palsy than that there should 
be a reflex spasm. To enter upon the theory of these affections 
is beyond the province of this book. A true reflex palsy can be 
recognized only by its history : so far as the paralysis itself is 
concerned, there are no positive diagnostic indications. 

Assumed Paralysis. — A paralysis may be assumed. When this 
is suspected, the tone of the muscles should be carefully examined, 
because in most palsies not accompanied by spasm there is a 
peculiar relaxation of the affected part ; and the absence of such 
relaxation would of course strengthen suspicion. Sometimes 
the deceit can be detected by watching the patient when off* his 
guard. Etherization may be resorted to. If the palsy be as- 
sumed, the mask will usually be thrown off* during the stage of 
semi-unconsciousness, and movements will be executed with the 
paralyzed limb. I have seen the nature of an assumed palsy 
made manifest by the patient's failing to counterfeit properly the 
peculiarities of the form of palsy which he was imitating. Thus, 
in an assumed hemiplegia the face was drawn towards the affected 
side. 

Hysterical Palsies. — The detection of the nature of the hys- 
terical palsy is sometimes a matter of great difficulty. In some 
cases the hysterical nature of the aff*ection is revealed by paralysis 
of the bladder, the intestines, the rectum, or other parts connected 
with organic life. Of course in some forms of organic palsies such 
symptoms are naturally present ; but their diagnostic importance 
consists in the fact that they are frequently seen in hysteria asso- 
ciated with hemiplegia and local palsies, which are rarely, when of 
an organic nature, accompanied by paralysis of the non-striated 
muscle-fibres of the visceral walls. 

The presence of other distinct symptoms of hysteria, either in 
the past or in the present, is of importance. Nevertheless a vio- 
lently hysterical person may be attacked by organic palsy, and 
I have also seen hysterical paraplegia occurring without other 
symptoms of hysteria, and without an hysterical history that 
could be made out. The hysterical palsy is apt to be transient 
and shifting in its character, to go and come suddenly, and not 
to conform in its minor phenomena with the sequences and co- 
incidences of organic palsy : thus, the reflexes are excited when 



26 DIAGNOSTIC NEUROLOGY. 

they ought to be depressed, or remain natural when they should 
be affected ; or sensory disturbances are present when they should 
be absent, or are situated in portions of the body not corresponding 
with the place where they ought to be in an organic palsy. An 
atypical case of paralysis should always be viewed with suspicion, 
especially when occurring in a woman. Moreover, it must not be 
forgotten that a man may suffer from hysteria. 

An hysterical paralysis may so closely simulate an organic one 
in its phenomena and its surroundings that it will for a time be 
impossible to decide whether it is organic or hysterical. It is, 
therefore, necessary to discuss in detail the diagnosis of hysterical 
palsy during the study of each of the different forms of paralysis. 

ORGANIC PALSIES. 

All paralyses are best arranged for study under six heads : 

First. General Palsy, in which the whole muscular system is 
involved. 

Second. Hemiplegia, in which the palsy affects one side of the 
body, or at least the arm and the leg of one side. 

Third. Paraplegia involving the legs. 

Fourth. Monoplegia, in which one member of the body is af- 
fected in the greater part of its muscular structure. 

Fifth. Multiple Palsies, in which two or more disconnected, 
distinct groups of muscles are paralyzed. 

Sixth. Local Palsy, in which a single muscle or a single group 
of muscles tributary to a single nerve is affected. 

GENERAL PALSIES. 

A true organic general palsy is a rare condition, and of course, 
except under extraordinary circumstances, cannot be absolute or 
complete, because the patient necessarily dies so soon as the trunkal 
muscles which are connected with respiration are affected beyond 
a certain degree. 

If, however, a lesion be so situated that it interrupts the pas- 
sage of the nervous course between the cortical brain-centres in 
which the impulse of voluntary movement originates, but does 
not affect the pathway between the automatic respiratory centres 



PARALYSIS. 27 

in the medulla oblongata and the respiratory muscles^ a complete 
general paralysis of voluntary movement may be consistent with 
life: such condition I have seen in an animal when the medulla 
has been divided from the pons, but I have never witnessed it in 
man, in whom it must be infinitely rare. 

Hysterical General Palsy. — Hysterical general palsy is ex- 
ceedingly rare, but Bruecke has reported six cases in which the 
principal muscles of the back and those of the four extremities 
were paralyzed, and there are others in medical literature. The 
nature of such a general palsy ought to be recognized by its 
coming on suddenly without being accompanied by severe apo- 
plectic or constitutional symptoms, such as mark a sudden attack 
of an organic general palsy, and by the presence of distinctly 
hysterical symptoms, or of a history of previous severe hysterical 
manifestations. 

Alcoholic Palsy. — A general loss of motor power is one of the 
symptoms of chronic alcoholism; 'but, with the knowledge of the 
habits of the patients, a mistake can hardly be made as to the 
cause of the failure of muscle-power. In the great majority of 
cases the arms are affected before, or more profoundly than, the 
legs. The disturbances of sensation are very marked; indeed, 
except in rare instances, sensation is much more profoundly in- 
fluenced in alcoholic poisoning than is motion, whilst the union 
of paralysis of sensation and of motion is excessively rare in organic 
general palsy : further, the peculiar tremors, the alterations of 
brain-function, also serve as sign-posts in alcoholic palsies. 

There are cases in which it is difficult to diagnose between an 
alcoholic palsy and true general paralysis of the insane. Dr. 
Camuset reports {Ann. MSd, PsychoL, 1883, vol. x. p. 201) cases 
in which tremors, general loss of muscular power, delirium of 
grandeur, unequal pupils, fibrillary contractions about the mouth, 
and all the supposed characteristic symptoms of the organic dis- 
ease, were present, but which resulted in cure upon the forced disuse 
of alcohol. The only test in these cases is the effect of abandoning 
alcoholic potations. (See General Paralysis of the Insane.) 

Interraittent Palsy. — An intermittent general palsy may be 
produced by malarial poisoning. A case of this character has been 
reported by Cavar6 ( Gaz. des H6p,, 1 853), in which the paroxysms 
lasted from five to eight hours, were of the quotidian type, and 



28 . DIAaNOSTIC NEUROLOGY. 

were cured by quinine. Romberg has reported a case of inter- 
mittent paraplegia also of the quotidian type and cured by qui- 
nine. There would appear, however, to be cases of intermittent 
general palsy not due to malarial poisoning. A most remarkable 
instance of this is that reported by Professor C. Westphal {BerL 
Klin. Wochenschrift^ 489), in which the patient suffered from a 
number of attacks, commencing with pain in all -four extremities, 
with rapid loss of power deepening into almost complete paralysis, 
ending in twelve or fourteen hours in sleep, with complete return 
of power on awakening. But the most remarkable features in 
this case were, that the sensibility was normal ; that the knee-jerk 
in the height of the paroxysm was wanting ; and that the elec- 
trical reactions were greatly weakened, and in some of the muscles 
entirely disappeared. After the paroxysm the electrical reactions 
became normal, except that the contractions were weak in those 
muscles which had been most affected. This patient recovered in 
four weeks. A case similar in character to this was reported by 
Hartwig {Inaug, Diss,, Halle, 1874), but the electrical reactions of 
the muscle did not disappear, although they became weak. In 
this case quinine at first appeared to prevent the paroxysms, but 
finally failed of effect, although the patient had had tertian fever 
some years before. Seven and one-half months after the begin- 
ning of this disease the patient had not recovered. 

Multiple Paralysis sirQulating- General Palsy. — A wide- 
spread multiple paralysis may closely simulate a general palsy, 
and, indeed, in certain conditions of the body may be said to pass 
into a general palsy : if two-thirds of the muscular structure be 
involved in a multiple palsy, the symptoms closely simulate a 
general paralysis, and if more than this proportion of the muscles 
are attacked, the symptoms become those of general palsy. 

Toxsemic General Paralysis. — An apparent general palsy 
which is the outcome of a multiple palsy is usually due to a 
toxaemia, either by alcohol or by such metals as lead or arsenic ; 
but it may be produced by a multiple neuritis. 

Ascending Paralysis. — The so-called ascending paralysis in 
its latter stages gives rise to a general palsy, the nature of which 
is to be recognized by the gradual but rapid spreading of the 
symptoms from the feet or the hands, or simultaneously from each 
towards the centre. The symptoms of ascending palsy in its 



PARALYSIS. 29 

various forms will be fully discussed under the head of Subacute 
Paraplegias. 

For diagnostic purposes Organic General Palsies may be divided 
into those which originate — 

First In the cerebral hemispheres. 

Second, In the pons. 

Third, In the spinal cord^ including the medulla oblongata or 
the intracranial portion of the cord. 

Cerebral General Palsy. — A general palsy of brain-origin 
is always incomplete, and is always associated with symptoms of 
profound alteration of other brain-functions. The lesion which 
produces it must aflPect both hemispheres of the brain, and is, 
when suddenly developed, almost invariably of the nature of a 
tremendous outpouring of blood into one hemisphere, or the rup- 
ture of an abscess, or a double apoplexy affecting each side of the 
brain. If the symptoms be slowly developed, they mark the 
presence of a very wide-spread and serious degeneration of the 
cerebral cortex, and, unless the attack dates back to infancy, are 
almost diagnostic of the so-called general paralysis of the insane. 
(See Disturbances of Intellection.) 

In some rare cases Spastic Infantile Paralysis is so wide-spread 
as to take the form of a general palsy, although, properly 
speaking, it is a multiple palsy, under which heading its symp- 
toms will be fully described. The character of such a pseudo- 
general palsy is to be recognized by the disease dating back to 
early childhood, and by the presence of distortions due to ex- 
cessive muscular contractions with more or less atrophy of the 
affected parts. There is also more or less pronounced arrest of 
mental development. 

Pons Palsy. — A suddenly-developed general palsy, due to 
lesion of the pons, is always the result of a hemorrhage which 
involves both sides of the pons. These cases are very rare, and 
are always accompanied by severe apoplectic symptoms. The 
recognition of a general palsy in severe apoplexy is excessively 
difficult, owing to the general muscular relaxation. Nothnagel 
affirms that there is no case in literature in which a patient has 
recovered consciousness with a double palsy due to hemorrhage in 
the pons. 



30 DIAGNOSTIC NEUROLOGY. 

A more or less pronounced general palsy may be gradually 
produced by a progressive lesion of the pons or by tumors pressing 
upon the pons. In a case recorded by Hallopeau (Archives de 
Physiol norm., 1876) the symptoms slowly involved first the 
right side of the body and afterwards the left, as the lesion pro- 
gressed through the pons. In a similar case reported by Stein 
{Memorabilien, 1863, 198) disturbances of sensation preceded, and 
exceeded in prominence, those of motion. 

The diagnosis of tumor of the pons must be made partially 
by exclusion : thus, an organic general palsy which is not of 
brain or of spinal origin is usually due to disease of the pons. 
The gradual implication of one side of the body after the other 
is very strong evidence that the lesion is in the pons. Disturb- 
ances of temperature, vomiting, a nearly complete facial palsy, or 
early implication of other nerves which arise in the pons, would 
confirm a diagnosis reached by exclusion. The characteristic 
symptoms may, however, be nearly or even altogether wanting. 

Bulbar General Palsy. — Theoretically, a general palsy might 
be produced by a minute hemorrhage into the central portions of 
the medulla. The medulla is, however, so small and so filled 
with vital nerve-cells that hemorrhage into it usually produces 
death, either instantaneously or in a few moments, — a result which 
also follows thrombus of the basilar artery, which supplies the 
respiratory centre. I know of but one case in literature in which 
it has been proved by a subsequent autopsy that the patient had 
survived hemorrhage into the medulla. This case is reported by 
Hughlings-Jackson in the London Lancet^ vol. ii., 1872, p. 770. 
Whenever a series of symptoms pointing towards apoplexy of 
the medulla oblongata is followed by recovery, the strong prob- 
ability is that there has been a temporary arrest of circulation 
in the anterior spinal artery or in the posterior (inferior) cerebellar 
artery, branches of the vertebral artery which supply the me- 
dulla. Any arrest of the circulation in the branches which the 
basilar artery sends into the medulla is followed by immediate 
death, since these do not anastomose, but are terminal arteries 
supplying the respiratory centres. 

People have been suddenly attacked with violent headache, 
giddiness, severe hiccough, various disturbances of sensation, 
great difficulty in or total loss of the power of swallowing and 



PARALYSIS. 31 

speaking, consciousness being preserved and the attack being at 
once followed by a more or less pronounced general palsy, with 
various local facial paralyses and great disturbances of respiration. 
There has also, in these cases, usually been excessive dyspnoea and 
general cyanosis, ending in death. In such attacks the lesion is 
thrombus or embolus in the vertebral artery^ with consequent 
softening in the medulla oblongata. In some cases of this char- 
acter, when the anterior pyramids have escaped, there has been no 
paralysis of the limbs ; and there have been instances in which 
only two extremities have been paralyzed. Anaesthesia has not 
been noted in any of the cases. 

Inflammatory Bulbar Palsy. — An acute palsy which may 
involve one, two, or more of the extremities and give rise to a 
monoplegia, hemiplegia, or general palsy, may be the result of a 
very rapid localized myelitic process occurring in the medulla. 
It seems to me most probable that in these cases the alleged in- 
flammatory change has been preceded by degeneration of the 
vessels, and consequent thrombus. How^ever this may be, the 
diagnosis of an acute lesion of the medulla is to be made out, in 
these as in all similar cases, by noting the paralysis of one or 
more of those organs whose nerves arise in the region of the 
medulla. A full statement of these palsies will be given under 
the head of Local Paralyses. 

A slowly-developed general palsy may result from a tumor or 
other progressive disease aflFecting the medulla oblongata, and 
Nothnagel asserts that it may be the only symptom of such a 
lesion. In such a case the absence of evidence of implication of 
the higher nerve-centres, and the presence of blindness or other 
symptoms of basal brain disease, might enable us to locate the 
lesion at the base of the brain, and yet it might at the same time 
be impossible to decide with certainty whether it was the pons 
or the medulla that was involved. Usually, however, the seat of 
the lesion is revealed by disturbance of the functions of the nerves 
which originate in or pass through the medulla : so that the 
absence of such disturbance indicates, but does not prove, that 
the pons is affected. Vomiting is, I think, more frequent in dis- 
ease of the pons than in affections of the medulla. 

Sensation in Bulbar Palsy, — Contrary to what might be ex- 
pected, loss of sensation in the extremities is not usually promi- 



32 DIAGNOSTIC NEUROLOGY. 

nent in a progressive general palsy of bulbar origin, and I know 
of no case in which there has been pronounced anaesthesia. In 
some instances complaint has been made of a feeling of stiffness, 
formication, or numbness in the extremities. The lack of dis- 
turbance of sensation is probably due to the fact that usually the 
lesion is a tumor springing from the brain-membrane and pressing 
upon the medulla : moreover, if the lesion has its seat in the me- 
dulla, it is commonly situated in the anterior portion. In either 
case death must result before the lesion is sufficiently advanced 
to affect markedly the sensory region. 

Vaso-motor disturbances have not been prominent in the re- 
ported cases of disease of the medulla, but diabetes insipidus and 
even true saccharine diabetes have been noted. 

Lenticular or Corpus Striatum G-eneral Paralysis. — Sudden 
loss of power in the tongue, lips, and muscles of mastication and 
deglutition has occurred from hemorrhage into the lenticular 
nucleus of each hemisphere, and in other cases slower, bilateral 
changes in these nuclei have produced a more gradual develop- 
ment of these palsies, with a general loss of power, making a 
picture resembling that of bulbar palsy. To these cases has 
been given the name of Pseudo-bulbar Paralysis. In a case 
recorded in the New York 3fedical Record none of the extremi- 
ties were paralyzed ; but, as a lesion of the lenticular nucleus 
usually causes hemiplegia, it is clearly possible for a double lesion 
to cause a general palsy which may very closely resemble that 
caused by disease of the medulla. 

HEMIPLEGIA. 

A hemiplegia in its fullest development affects the arm, leg, 
face, and tongue; the paralysis in the arm and leg is complete; 
the paralysis of the face is incomplete, and usually affects almost 
solely the muscles of expression about the mouth, the upper por- 
tion of the face ordinarily responding to the will. The muscles 
of chewing are very rarely involved. The corner of the mouth 
is usually drawn towards the sound side, but the tongue protrudes 
towards the paralyzed side, owing to the intact genio-glossus muscle, 
which thrusts the tongue forward, not being opposed by its fellow. 
In old hemiplegics the face is sometimes drawn towards the par- 
alyzed side by the late contractures in the paralyzed muscle, and 



PAEAL.YSIS. 33 

in acute hemiplegia, if the paralysis be accompanied by spasm, a 
similar distortion may occur. The palsy in these cases of facial 
distortion from secondary spasm is to be recognized by the gen- 
eral immobility of the paralyzed side, by the absence or softening 
of the natural wrinkles and lines of expression, and by the loss 
of the ability to close the eye. Sometimes, when spasm obscures 
the paralysis, on forced smiling the loss of power is evident. 

The muscles of the trunk and of mastication are very rarely par- 
alyzed in hemiplegia, unless the base of the brain or the medulla 
be involved. The ordinary respiratory movements continue, be- 
cause the lesion is situated above the automatic respiratory centre. 
More than this, in most cases the muscles of the trunk respond 
to the will to a certain extent: frequently, however, when the 
patient contracts the muscles either of mastication or of respira- 
tion as powerfully as he can, it will be noted that the muscles 
upon the sound side act more vigorously than those on the para- 
lyzed side. The most plausible theory w^hich has yet been 
brought forward to account for the escape of the masticatory and 
trunkal muscles is that of Broadbent. The muscles which escape 
are always those that are habitually used together : thus, the two 
masseters in eating contract simultaneously, and the respiratory 
muscles of the two sides of the trunk always act in unison. It 
is believed that by this habitual action the pathways are opened 
between the centres in the spinal cord which control the muscles 
under discussion, so that these two centres finally act in unison, 
and when one of them receives an impulse from a hemisphere 
this impulse overflows to its fellow. For this reason, if the lesion 
occur in the left hemisphere the right hemisphere is able to reach 
by its impulse the centres on each side of the cord connected with 
mastication or wath respiration. 

According to Dr. W. R. Gow^ers, immediately after the hemi- 
plegic stroke the sound leg sometimes distinctly shares in the 
weakness. This also is to be explained on the theory of habit- 
ual action. Dr. Gowers further states that in some cases of hemi- 
plegia when the patient tries to show his teeth the mouth may be 
motionless on the paralyzed side, and yet on smiling there may 
be little or no difference in the action of the two sides. Dr. 
Gowers explains this by supposing that emotional movements are 
indifferently innervated from either hemisphere. 

3 



34 DIAGNOSTIC NEUROLOGY. 

Hysterical Hemipleg'ia. — Hemiplegia is a very frequent form 
of hysterical palsy, but in most of these cases one extremity is 
distinctly more aflPected than the other, and paralysis of the face, 
although it does occur, is so rare that any case in which it is 
present is probably not hysterical. The palsy is rarely com- 
plete : so that a patient unable to walk or even to stand may be 
able to raise the foot when in bed. There is usually more or less 
pronounced loss of sensation in the paralyzed part, and the coex- 
istence of a hemiansesthesia with hemiplegia should always incite 
to a very careful diagnostic examination. The faradic contractil- 
ity is usually normal, but in some cases galvanic sensibility is lost. 
Such loss is a very strong indication that the attack is hysterical. 
The reflexes which are usually excited in the first days of or- 
ganic palsy are in most cases of hysteria not affected, and may be 
lessened. By attention to the points just enumerated, and to the 
history of the patient, the diagnosis can usually be made with- 
out difficulty. In some cases aid may be obtained by the appli- 
cation of powerful electrical currents to the affected membranes, 
or by the practice of the so-called metallo-therapy. Rapid alter- 
ations of sensibility produced in this way are very characteristic 
of hysteria. Sudden changes in the degree of paralysis are almost 
pathognomonic of hysteria : they do occur in cases of brain-tumor, 
but not in cases of cerebral hemorrhage. 

Diagnosis between True and False Hemiplegia, — True hemi- 
plegia is usually the result of a focal brain-lesion, but it is neces- 
sary to distinguish carefully between a true hemiplegia and one 
in which a multiple paralysis affects various groups of muscles 
upon one side of the body. If a majority of the leg- and arm- 
muscles on one side are affected by a multiple palsy, the symptoms 
may very closely simulate those of hemiplegia, but the true nature 
of the affection can usually be recognized by the irregularities in 
the intensities of the palsies. In a brain-hemiplegia the law is 
that the nearer the muscles are to the trunk the less apt are they 
to be completely palsied. Thus, the forearm is more thoroughly 
affected than the upper arm, and the leg than the thigh. In 
multiple paralyses simulating hemiplegias this rule is almost in- 
variably departed from. A hemiplegic multiple palsy may be 
due to disease of the brain-cortex, and might well be considered 
to be a double monoplegia, — i.e., a brachial and a crural monoplegia. 



PARALYSIS. 35 

In this case the rule concerning the relative condition of the mus- 
cles just laid down does not always hold, and it is not always pos- 
sible to distinguish the nature of the affection except by the 
collateral symptoms, which in the multiple palsy will generally 
show either that the brain-cortex is affected, or that there are 
two distinct lesions. When a hemiplegia dates back to childhood, 
and is associated with marked contractures, it is usually a multiple 
brain-palsy. (See Spastic Infantile Paralysis, under heading of 
Multiple Palsy.) 

Spinal Hemipleg-ia. — A hemiplegia may be of spinal origin, 
due to pressure of a tumor or to hemisection of the upper cord : 
such hemiplegia is rarely complete, and is almost always asso- 
ciated with hemiansesthesia, the paralysis of sensation invariably 
being on the opposite side of the body from that of motion. When 
cerebral hemiplegia and hemiansesthesia coexist, they are inva- 
riably on the same side of the body, except in very phenomenal 
cases in which the paralysis of motion and the loss of sensation 
are due to different foci of disease situated in opposite brain- 
hemispheres. 

Cerebral Hemiplegia. — When in any case the existence of a 
true brain-hemiplegia has been determined, the next step is to 
find out whether it has developed suddenly or gradually. 

Sudden or abrupt brain-hemiplegias may be due to cerebral 
hemorrhage, to arrest of cerebral circulation by an embolus or 
thrombus, to an abscess, or to a tumor. Progressive or slowly- 
developing hemiplegias are the result of abscess, localized cerebral 
softening, or other progressive focal brain-degeneration, including 
tumors and gummatous inflammation. 

In a progressive hemiplegia very little can be learned from the 
palsy itself as to the nature of the lesion. A paralysis produced 
by softening is usually more steadily progressive and less variable 
than one caused by tumor ; the hemiplegia of tumor is, in its 
turn, surpassed in its perpetual variability by a hemiplegia of 
specific origin. 

Abrupt hemiplegias produced by tumors are usually the result 
of sudden local congestions around the tumor, and are to be dis- 
tinguished by their incompleteness and by the rapidity with which 
they subside. Their diagnosis is especially to be made out, how- 
ever, by the presence of headache, epileptic fits, choked disk, or 



36 DIAGNOSTIC NEUROLOGY. 

other evidences of progressive cerebral disease. When a complete 
and permanent hemiplegia occurs suddenly in a case of progressive 
brain-disease, it is usually due to hemorrhage. The absolute 
abrupt hemiplegia^ which sometimes results from the bursting of 
an abscess in the ventricle^ is apt to develop almost at once into a 
general palsy, and is always accompanied by stormy cerebral dis- 
turbance, such as profound coma, great alterations of temperature, 
convulsions, etc., and is followed by death in a few hours. If the 
previous history of the case be known, the nature of the attack 
can readily be surmised. 

Abrupt Cerebral Hemipleg-ia. — An abrupt complete hemi- 
plegia may be due either to a hemorrhage into the substance of 
the brain, to thrombosis, i.e., arrest of the circulation by the for- 
mation of a coagulum inside of the artery, or to embolism, i.e., 
arrest of circulation by the lodgment of a small mass swept from 
a diseased heart- valve or other focus into the general circulation. 

Diagnosis between Embolism and Hemorrhage, — In the great 
majority of cases the cause of a sudden hemiplegia is a rup- 
ture of a blood-vessel and the formation of a clot in the 
brain. A hemiplegia due either to a clot or to an arrest of cir- 
culation may occur with or without the symptoms of apoplexy. 
The diagnosis between hemorrhagic and embolic hemiplegia is 
often impossible. Various symptoms connected directly with the 
paralysis have been assigned from time to time as diagnostic of 
the arrest of cerebral circulation, but these symptoms are of no 
diagnostic value, and they shall not here be discussed. When 
the onset of a hemiplegia is accompanied by violent action of 
the heart, a full, strong pulse, and a general expression of great 
systemic power, it is almost invariably due to a clot; but a clot 
may be formed without such systemic reaction, and it is in such 
cases that the difficulty of diagnosis especially exists. It is as- 
serted by some writers that hemiplegia accompanied by aphasia is 
usually the result of arrest of circulation ; but in a number of 
autopsies upon such cases I have found a clot, and I believe that 
even this conjunction of symptoms is most frequently due to 
hemorrhage. When physical signs indicate the presence of nu- 
merous small vegetations upon the valves of the heart, or when 
these valves are undergoing rapid destruction, as in some cases 
of ulcerative endocarditis, a sudden hemiplegia may be very 



PARALYSIS. 37 

reasonably suspected to be due to embolism. This suspicion is 
of course increased if previous embolic attacks, either of the 
brain or of other parts of the system, have occurred. Thus, in a 
case which came under my notice there had been previous attacks 
of violent local pains in various parts of the muscular system, 
associated with pronounced local disturbances of circulation, as 
show^n by discoloration of the parts. It must also be remembered 
that large numbers of minute miliary aneurisms may exist in the 
brain and produce repeated attacks of slight hemiplegias, due to 
the formation of very slight clots outside of the vessels. If such 
a condition were coincident with cardiac disease it might very 
well be mistaken for embolic. According to Bourneville {jStudes 
cliniques et thermometriques sur les Maladies du Systhne nerveux, 
Paris, 1872), there is usually immediately after the formation of 
a thrombus a slight fall of temperature, followed by a slight 
rise, which may not pass beyond the norm, or in rare cases 
reaches to 40° C, and is apt to be accompanied by remarkable, 
irregular oscillations. Then there is usually a prolonged period 
in which the temperature remains nearly uniform, a little above 
normal and sometimes gradually rising, but not reaching a point 
equal to that very frequently attained in cerebral hemorrhage. 
These changes of temperature are not suflSciently different from 
those seen in cerebral hemorrhage to be of much diagnostic im- 
portance : they differ chiefly in intensity. The first fall and the 
subsequent rise of temperature are less than those which occur 
in hemorrhagic apoplexy, so that if in any case the thermometrical 
changes are very great, the symptoms are probably due to hemor- 
rhage. A very great rise of temperature immediately after a 
hemiplegic apoplexy may be considered as pathognomonic of clot, 
and usually indicates a fatal termination. Bourneville has also 
noted that after death from acute brain-softening the tempera- 
ture falls more rapidly than after cerebral hemorrhage. 

Diagnosis of Position of Clot, — The diagnosis of the exact 
seat of a brain-lesion in hemiplegia involves a knowledge of the 
course of the motor fibres which run from the spinal cord to the 
cerebral cortex. The region of the cortex in which these fibres 
arise is so large that, unless by extraordinarily extensive lesions, 
only monoplegias or local palsies are produced. (See Local Palsies.) 
The motor fibres converge from the brain-cortex into a fasciculus 



38 DIAGNOSTIC NEUROLOGY. 

(see Fig. 1), which, in its entirety, is known as the direct cerebr^cU 
tract, or as the peduncular tract. This band of fibres (m) runs be- 
tween the external border of the thalamus optici (T. O.) and the 
lenticular nucleus (L. N.) of the corpus striatum, and constitutes 
a portion of the internal capsule so called. None of these motor 
fibres have been traced either to the optic thalamus or to the len- 

FlG. 1. 




Diagrammatic representation of course of direct cerebral tract. C. N., caudate 
nucleus; m, fibres of direct cerebral tract; c, claustrum ; T. 0., optic tbalamus ; 
L. N., lenticular nucleus. 

ticular nucleus. The fasciculus passes from the brain-peduncles 
into the pons, and finally into the medulla oblongata. 

Lesion of Thalamus Optici. — Theoretically, the only lesions 
in the interior of the brain which should produce hemiplegia are 
those situated in the direct cerebral tract. In accord with this, 
clinical records show that hemorrhages confined in their influ- 
ence to the thalamus optici do not produce motor symptoms. It 
is true that often there is a temporary paralysis produced by hem- 
orrhage into the thalamus, and that lesions of the middle third 
of the thalamus are not rarely accompanied by permanent hemi- 
plegia. The middle third of the thalamus is that part of the 
ganglion in which the pressure from within would most affect the 
internal capsule and the peduncle. It would appear, therefore, 
that the paralysis in these cases is due to pressure upon the direct 
cerebral tract. 

Lesions of Corpus Striatum. — Lesions of the corpus stri- 



PARALYSIS. 39 

atum usually produce hemiplegia, which may be as complete as 
when the lesion is in the internal capsule, affecting the face, 
tongue, trunk, and extremities. Whether the paralysis in these 
cases is always due to pressure upon the internal capsule or not is 
an unsettled question. There is some reason for believing that 
the corpus striatum is in some way connected directly with volun- 
tary motion. At present there is no method of diagnosis between 
lesions in the internal capsule and those in either portion of the 
corpus striatum, — i.e., in the caudate nucleus or the lenticular 
bodies. 

Facial Palsy. — In all cases of hemiplegia in which the lesion 
is in the central brain the paralysis of the face is upon the same 
side as that of the body. 

Disorder of Sensation in Hemiplegia. — A lesion in the central 
brain very rarely affects sensation : for a discussion of such cases 
see the chapter on Disturbances of Sensation. In the medulla 
oblongata, the pons Varolii, the peduncles, and also in certain 
portions of the internal capsule, the motor and the sensory fibres 
are sufficiently close to be involved in a common lesion. In the 
peduncles slowly-growing tumors are the only lesions that produce 
purely motor hemiplegia : under such circumstances it is not pos- 
sible during life to locate the lesion with certainty. 

When hemiansesthesia and hemiplegia are produced by a focal 
brain-affection they coexist upon the side of the body opposite 
to the lesion, since the injury is situated above the decussation 
of both the motor and the sensory fibres. The detailed discussion 
of the exact position of the lesion in such cases must be deferred 
to the chapter on Disturbances of Sensation. 

Hemipleg-ia with Aphasia. — A clot in the brain may give 
rise to hemiplegia with aphasia : the diagnosis of the seat of the 
lesion in these cases will be fully discussed in the chapter on 
Aphasia. 

Hemipleg-ia from Lesion in Pons. — A hemorrhage into the 
pons Varolii may produce a simple hemiplegia which cannot be 
distinguished from one in the central brain-region ; often, how- 
ever, there are distinctive symptoms. In the small space occupied 
by the pons, there are gathered together motor and sensory fibres, 
as well as fibres belonging to the facial, hypoglossus, abducens, 
and trigeminus nerves : the symptoms of a clot in this region 



40 DIAGNOSTIC NEUROLOGY. 

may be, therefore, very various. It is, however, exceptional for an 
acute lesion of the pons to affect other than the facial nerve and 
the general motor tract. When tlie abducens nerve is implicated, 
there is an internal squint; it depends upon the portion of the 
pons attacked whether the misdirected eye is upon the side of the 
lesion or opposed to it : thus, if a right-sided lesion be in the 
upper half of the pons the squint will be in the left eye, but if 
in the lower half, in the right eye : in like manner in hypoglossus 
paralysis the tongue when projected turns from or towards the 
paralyzed extremities according as the lower or the upper portion 
of the pons is aflFected.* According to Nothnagel, a conjugated 
palsy of the abducens and the internal rectus muscle is diagnostic 
of lesion of the pons. General oculo-motor palsy can occur only 
when the lesion is a tumor sufficiently large to press upon parts 
near to but outside of the pons. 

Facial Palsy. — In the majority of cases of hemorrhage into 
the pons, facial palsy is either wanting altogether, or is upon the 
same side of the body as are the other paralytic symptoms. 
Under these circumstances it is the proximal half of the pons — 
i.e., that which is next to the peduncle of the cerebrum — that is 
affected. 

Small hemorrhages or other lesions in the lower portion of the 
pons may cause hemiplegia without paralysis of the facial nerves ; 
if the hemorrhage be at all large, there will be paralysis of the facial 
nerve opposite to the affected arm and leg. This alternate or crossed 
paralysis is produced by a lesion in the lower half of the pons, — 
i.e., the half nearest the medulla oblongata, — because a lesion so 
situated is below the decussation of the facial nerves, but above 
the decussation of the general motor tract. The facial palsy pro- 
duced by apoplexy of the pons is usually more complete than that 
caused by lesions in the cerebral hemisphere, but even in it the 
frontal and orbicular muscles almost invariably escape. In croased 
paralysis the fibres of the facial nerve are affected below their 
origin in the facial nucleus. This nucleus belongs really to the 
spinal system, and is a trophic as well as a motor centre. Con- 
sequently, in alternate palsy the facial muscles are separated from 

^ The effect of palsies of these and all other individual nerves will be dis- 
cussed in detail in the section on Local Palsy. 



PARALYSIS. 41 

their trophic centres^ and undergo degenerations similar to those 
which occur in the muscles of the extremities when the spinal 
trophic centres are involved. The nature of these degenerations 
will be discussed in detail in the section on Trophic Changes. It 
is enough for the present to state that^ as first observed by Prof. 
Rosenthal (Wiener Med., Halle, 1863), the facial nerve rapidly 
loses its faradic excitability, and develops an excessive sensibility 
to galvanic stimulation.* 

Crossed paralysis is usually due to a lesion in the lower half 
of the pons, but is not absolutely diagnostic of such lesion, as it 
may be caused by a lesion in the medulla oblongata. Thus, Rondot 
reports {Journ, de Med, de Bordeaux, vol. xiii. 304) a case in 
which softening was confined to the left pyramidal tract in the 
medulla, and H. Senator {Arch, fur Psych, u. Nervenh., xi. 3) one 
with softening extending from the calamus to the restiform body, 
due to thrombus of the left vertebral artery. 

Crossed Oculo-Motor Palsy. — There are certain cases of 
hemiplegia in which the face, arms, and leg are paralyzed upon 
one side, although the oculo-motor nerve is affected on the opposite 
side of the body, as is shown by dilatation of the pupil and ptosis. 
In these cases there are usually temporary or permanent disturb- 
ances of sensation on the side of the hemiplegia. Very frequently 
there are marked disturbances of temperature, the paralyzed side 
being from two to nearly five degrees warmer than the normal 
side. The lesion under these circumstances is in the cerebral 
peduncle. (For cases, see Ramey, Revue de M^d., 1885, 402.) 
Although Budge and AfasanieflF place the centre which presides 
over the contractility of the bladder in the peduncles, it is rare for 
the rectum or the bladder to be affected in peduncular hemorrhage. 
It is much more frequent for oedema or reddish coloration of the 
skin to show evidences of vaso-motor disturbance. 

Ancesthesia in Lesion of Pons. — Anaesthesia, usually absent, 
may be present in lesion of the pons. So far as the extremities are 
concerned, it always affects those which are paralyzed. In some 
cases hypersesthesia of the paralyzed part has been noted directly 



■^ Although this change of electrical relation has been noticed by several 
observers, I know of no recorded case in which the exact seat of the lesion 
has been confirmed by an autopsy. 



42 DIAGNOSTIC NEUROLOGY. 

after a hemorrhage into the pons^ but it always disappears in the 
course of two or three days. 

Professor Leyden has described a case of left hemiplegia in 
which a high grade of anaesthesia existed in the course of the right 
trigeminus nerve^ and also in the left extremities; and Hugh- 
lings-Jackson states that he has seen a similar crossed sensory 
palsy. It would appear, therefore, that there may be alternate 
sensory as well as alternate motor palsy in disease of the pons. 
Under these circumstances it is probably the lower half of the 
pons that is affected. 

Prog-ressive Hemipleg'ia from Lesion of Pons. — A progres- 
sive hemiplegia with or without sensory disturbances, and with or 
without paralysis of the abducens, hypoglossus, or trigeminus 
nerves, may be produced by a slowly progressive lesion on one 
side of the pons. The diagnosis of such an affection must be 
made out by an application of the facts and principles which have 
just been discussed in detail in the consideration of acute pons 
lesions. As already stated, the gradual conversion of a hemiplegia 
into a general palsy is very characteristic of a tumor in the pons or 
in the membranes beneath it. I know of no studies of tempera- 
ture under these circumstances; but very marked differences in 
temperature of the two axillae, and especially in the temperature of 
exposed extremities, are to be looked for. In any case of pro- 
gressive hemiplegia with a persistent marked increase of the tem- 
perature of one axilla, the probabilities are that the lesion is on 
one side of the pons. 

PARAPLEGIA. 

Paraplegia is a more or less complete palsy confined to the 
lower limbs, and may be either functional — i.e,, reflex or hysterical 
— or organic, it being understood that for the present we are 
forced to class under functional paraplegia cases in which after 
death no lesion can be demonstrated by the microscope. 

Functional Paraplegia. 

Reflex Paralyses. — Paralysis of a single group of muscles, or 
more usually of a number of associated groups, may result from 
the irritation of peripheral nerve-filaments not immediately con- 



J 



PARALYSIS. 43 

nected with such muscles. Instances of this are the various 
atrophic palsies associated with traumatisms^ inflamed joints, and 
other surgical affections, which will be discussed in detail under 
the heading of Multiple Palsy. Omitting these surgical cases, the 
most usual form of reflex paralysis is paraplegia. For many 
years it has been known that paraplegia is not rarely associated 
with severe organic diseases of the genito-urinary organs, and in 
1864 Brown-S^quard showed that similar loss of power in the 
legs may be produced by irritations of the intestines or other 
viscera, and gave to the affection the name of Reflex Paralysis. 
It does not lie within the scope of the present work to enter upon 
a detailed discussion of the pathology of renal paraplegia. Suffice 
it to state that in my opinion the more serious cases are the result 
of an organic disease of the cord (see page 44). This explanation, 
however, cannot be given of the not extremely infrequent cases 
in which a complete paraplegia without anaesthesia has occurred in 
a person suffering from a genito-urinary irritation and has disap- 
peared within two or three days after the removal of such irrita- 
tion. To cases of this character the name of Reflex Paraplegia 
should be restricted. The point of irritation may be in the in- 
testines, and it is possible that in some of the cases in which 
paraplegia occurs during a severe dysentery the symptoms are 
reflex.* Usually, however, the paraplegia persists long after the 



■^ Almost any form of paralysis may be developed during the convalescence 
from the acute fevers or exanthemata proper. There may be nothing in the 
paralysis to distinguish it from cases of similar character produced by other 
causes. Experience has, however, shown that in a considerable proportion 
of these post-febrile or post-exanthematous diseases the symptoms are simply 
a motor paraplegia, and are much more amenable to treatment than in ordi- 
nary paralysis of the same class. I have seen various instances of paraplegia 
following acute dysentery and typhoid fever in which I was unable to detect 
symptoms different from those produced by ordinary very mild myelitis lo- 
cated in the motor tract, but in which more or less perfect recovery took place 
in the course of a few months. The lesion in some of these cases is a multiple 
neuritis (see Multiple Neuritis) ; but that a myelitis may occur, and even be 
fatal, after one of these fevers, is show^n by the case reported by Westphal 
(Arch, fur Psychiat.^ Bd. iv., 1873-74.) In this case the paralysis appeared 
on the eleventh day of smallpox, and resulted fatally in four weeks. At the 
post-mortem small foci of softening were found throughout the cord. It is 
probable that the myelitis was septic. Cases of dysenteric paraplegia have 
also been reported in which the autopsy has revealed diffused myelitis. 



44 DIAGNOSTIC NEUROLOGY. 

cure of the dysentery or diarrhoea, and the disease must therefore 
be looked upon as something more than a reflex affection. My 
belief is that in some of these cases there is organic change in the 
cord, but that in others there is only a condition of profound de- 
pression of the spinal function from loss of nutritive tone. The 
facts that in most cases the symptoms gradually yield to treatment, 
and that sensation is rarely if ever seriously affected, indicate that 
there is no serious myelitis. A true reflex paraplegia may be 
produced by the irritation of worms in the intestinal tract. A 
number of cases have been reported in which the passage of lum- 
bricoid or tape worms has been followed by immediate relief of 
the paralytic symptoms. Dr. Moll, of Vienna, has reported a 
case in which the arms, and not the legs, were paralyzed, with an 
immediate cure of the palsy on the expulsion of the tape-worm. 

In reflex paraplegia sensation is not .disturbed, the bladder is 
not paralyzed, and there are no trophic changes. 

Major Renal Paraplegia. — There have been not a few cases 
of genito-urinary disease, and especially of renal calculus, in which 
symptoms far more severe than those just spoken of were present. 
The motor paralysis in such cases increases until it becomes 
almost complete, and is accompanied with marked perturba- 
tion of sensation. Not rarely violent pains shoot down the 
affected limbs, and are associated with various parsesthesise, and a 
continually deepening anaesthesia which may become complete. 
In the earlier stages the reflexes are sometimes exaggerated, but 
sooner or later they grow less active, and in most cases finally dis- 
appear. The muscles rapidly waste, and the electrical reactions 
of degeneration appear. Bullae, bed-sores, and other trophic 
changes increase : all control over the bladder and rectum is lost, 
and the patient finally dies from exhaustion. In some cases the 
progress of the disease is very rapid ; in others it is slow, and arrest 
with partial recovery may occur if the original irritative lesion be 
removed. The symptoms in these cases are due to a secondary 
myelitis, which in some instances is certainly produced by a neuritis 
creeping up the nerve-trunk implicated in the original disease, 
and finally reaching the cord itself. I am inclined to believe, 
however, that a myelitis may be induced without this ascending 
neuritis, or in a manner parallel to that in which the condition 
of violent functional excitement of the spinal cord known as 



PARALYSIS. 45 

tetanus is caused by an irritation of a peripheral nerve-filament. 
This secondary myelitis may be produced by any sufficiently severe 
and permanent irritation of nerve-filaments. Cases have been 
reported in which it has followed a direct traumatism of a nerve- 
trunk. 

In some cases of pelvic or abdominal inflammations in which 
paraplegia has been supposed to be reflex^ the symptoms have been 
due to a direct implication of the sacral nerve in the lesion, and 
a consequent wide-spread neuritis of the lower extremities. 

Hysterical Paraplegia. — Hysterical paraplegia is frequent, 
and may simulate any of the organic varieties. It usually de- 
velops rapidly, but may come on slowly. It may be associated 
with the most marked muscular relaxation, or with the greatest 
rigidity, due to excessive contractures. The knee-jerk (see Re- 
flexes) is in some cases normal, in others it is absent. Perhaps in 
the majority of instances it is exaggerated. The muscles do not 
undergo rapid trophic changes, but a slow progressive wasting of 
them may occur. It has been asserted by Gowers that the ex- 
istence of ankle clonus (see Reflexes) is proof of the organic 
nature of a paraplegia ; but this is not correct. I have seen a 
paraplegia which had lasted for many months, associated with 
greatly exaggerated knee-jerk and pronounced ankle clonus, get 
well in a few days during the administration of subnitrate of 
bismuth. The most characteristic symptoms are connected with 
sensibility : in some cases there is excessive hyperaesthesia, with or 
without pain ; more frequently the sensibility is lessened or abol- 
ished ; usually the muscular sense is at least as much affected as is 
cutaneous sensibility. In those forms of organic paraplegia which 
are most frequently simulated by the hysterical affection, sensi- 
bility is not altered. According to my own experience, a distinct 
girdle sensation is diagnostic of organic disease ; but hysterical 
patients are very prone to take on suggested symptoms : conse- 
quently they frequently complain of the girdle sensation after 
it has been mentioned in their presence. M. Charcot appears to 
believe that the presence of fibrillary muscular contractions is 
diagnostic of organic diseases, but this is denied. (See Revue cle 
3Ied., 1885, p. 229.) The diagnosis of hysterical paraplegia is 
usually to be made out by considering the past history of the 
patient, the mode of onset, the condition of the sensibility, and 



46 



DIAGNOSTIC NEUROLOGY. 



the shifting nature of the alterations of motility and of sensi- 
bility. It is also asserted, but on this point I am not positive, 
that in those cases of hysteria in which there are contractures, — 
cases in which the diflBculty of the diagnosis is usually greatest, — 
muscular relaxation takes place in the early stages of etheri- 
zation, whilst in the organic spastic palsy the anaesthetic exerts 
little or no influence on the muscles. Unless the diagnosis can 
be made by the use of an anaesthetic, there are certainly cases in 
which it is impossible to decide, within a brief space of time, 
whether the paralysis is organic or hysterical. 



Organic Paraplegia. 

Anatomy of the Spinal Cord. — In order to recognize the dif- 
ferent forms of organic paraplegia it is necessary to have a clear 
understanding of the physiological regions of the spinal cord, and 
of the functions connected with each of these regions. In the 
following diagram it will be noticed in the first place that the 

Fig. 2. 




cord is composed of gray and white matter, and that in the gray 
matter of the cord are situated certain cells whose places are 
marked in the diagram by dots. 

These cells are furnished with long processes, which are the 
origin of nerve-roots. They are ganglionic in their nature, and 
have the double power of exciting motion and of influencing 
nutrition in the muscles. When a disease attacks these gan- 



J 



PARALYSIS. 47 

glionic cells, paralysis of the muscles ensues, with rapid wasting 
and change in the electrical reactions. (See Trophic Changes.) 

Placed laterally to the gray matter are the so-called lateral 
columns (A, Fig. 2), masses of nerve-fibres, which pass along the 
cord, constantly receiving accessions from the nerve-roots, and in 
the upper part of the medulla oblongata become the pyramidal 
tracts, which, crossing over to the opposite side, pass through the 
pons Varolii into the peduncle and then upward as the direct 
cerebral tracts. Situated on the extreme borders of the an- 
terior fissure in the white matter of the cord are the so-called 
columns of Turch, — composed of white nerve-fibres passing up- 
ward to the brain (C). Their functions are similar to those of 
a lateral column, — namely, to conduct impulses from the brain. 
The essential difference is that the lateral columns cross over to 
the opposite brain-hemisphere, whilst the columns of Turck pass 
directly to the hemisphere of the same side : hence the lateral 
columns are sometimes spoken of as the crossed pyramidal tracts, 
and the columns of Turck as the direct pyraraidal tracts. 

From the gray matter of the cord pass out the anterior and 
posterior nerve-roots. The region of white matter in the neigh- 
borhood of the posterior roots is known as the p)Osterior root- 
zones^ and is connected with sensation and co-ordination, so that 
in disease of this portion of the cord these functions are especially 
affected. In immediate contiguity with the posterior fissure are 
the small tracts of white matter known as the columns of Goll (B). 
A disease which attacks the posterior root-zone usually affects also 
the columns of Goll, but there are very few cases on record of 
primary diseases of the columns of Goll : so that their functions 
are at present not definitely known. 

Out of the spinal cord spring nerve-fibres, which pass into the 
so-called sympathetic ganglia. Such fibres arising in the cervical 
spinal cord pass through the cervical sympathetic ganglia, and go 
with the carotid artery into the cranial cavity. Some of these 
fibres are probably distributed as vaso-motor nerves of the brain 
and its membranes; others reach the eye, and become con- 
nected with the movements of the pupil. Certain spinal sym- 
pathetic filaments pass from the cervical dorsal region to the 
heart, and are essentially connected with its movements. It is 
owing to these facts that diseases of the cervical dorsal cord are 



48 DIAGNOSTIC NEUROLOGY. 

SO frequently associated with derangements of the pupillary and 
cardiac movements. 

In the lumbar cord are placed centres which preside over the 
genito-urinary tract, and hence disease of this portion of the cord 
is prone to be connected with priapism, impotence, or other genital 
symptoms, and with very early spasmodic or paralytic affections 
of the bladder. 

Paraplegia from Multiple Paralysis. — When a multiple 
palsy attacks the lower portion of the spinal cord especially, it 
may produce a paraplegia which might be mistaken for one due 
to general myelitis. Under these circumstances, however, it will 
usually be found that some muscles of the lower extremities have 
escaped, or that they have been irregularly affected. In a mye- 
litic paraplegia the general rule is that the muscles farthest from 
the trunk are first paralyzed ; although this does not apply to cases 
of transverse myelitis or to some rare instances in which localized 
regions of the cord are especially attacked. Almost always in 
these cases of multiple palsy some muscles in the upper extremity 
will be found to be affected. The diagnosis of the true disease, 
however, is to be especially based upon the rapid wasting of the 
affected muscles and the change in their electrical reactions. 
Cases of multiple paralysis which most resemble myelitic para- 
plegia are those due to lead or arsenical poisoning. That such 
cases belong in the multiple palsies is shown by the trophic 
changes which are present and by the irregularities in the group- 
ing of the palsies. The diagnosis between these cases and those 
of ordinary poliomyelitis or of multiple neuritis will be fully 
considered under the head of Multiple Palsies. 

Organic paraplegia having been found in any case, the first 
point to be settled is as to the length of time required for the de- 
velopment of the symptoms. For diagnostic purposes all these 
cases are arranged under three heads : 

First Those in which the symptoms are developed with great 
rapidity. 

Second. Those in which some days are required for the full 
production of the paraplegia. 

Third, Those in which the symptoms progressively increase 
during a period of many months or years. 



PARALYSIS. 49 

Abrupt Paraplegia. 

When the symptoms of paraplegia develop in the course of 
two or three days, and are not connected with a traumatism, they 
are due either to a hemorrhage into the cord, to a hemorrhage 
into the vertebral canal outside of the cord, to ascending (or Lan- 
dry^s) paralysis, or to a very acute myelitis. 

Spinal Apoplexy. — In some cases of sudden paraplegia the 
patient falls to the ground. Very rarely the cerebral disturbance 
is so marked that the attack may appear to be a true apoplexy ; 
but when consciousness is restored it will be found that there 
is a complete palsy of the lower limbs, both of sensation and 
of motion. In the very beginniog of the attack there may be 
violent pains, but these soon subside. Theoretically, spinal apo- 
plexy might be expected to produce localized palsies in the parts 
below the lesion, but practically the cord is so small that whenever 
hemorrhage does occur it influences the whole of the cord, so that 
both sides of the body are aflFected. Pain is not usually a promi- 
nent symptom, even at the beginning of an attack. The an- 
aesthesia is very characteristic. It is usually complete, but it is 
especially to be recognized by its abrupt termination in a line 
or a very narrow zone which extends entirely around the body. 
The bladder and rectum are completely paralyzed. 

Haematomyelitis. — In some cases of hemorrhage into the cord 
the sudden paraplegia has been preceded by evidences of subacute 
myelitis, such as fever, formications, partial or complete paral- 
ysis of the bladder, girdle sensations, spasms, or muscular twitch- 
ings. To these cases the name of hsematomyelitis has been given, 
but they are to be viewed as instances of spinal apoplexy occurring 
in a myelitis. Softening of the cord and other evidences of in- 
flammation may be found after death in the neighborhood of the 
clot, even when there have been no distinct symptoms of myelitis 
before the hemorrhage. The natural explanation of these cases is 
that the inflammation of the cord was provoked by the hemorrhage. 

Hemorrhag'e into Spinal Membranes. — In other cases of very 
acute paraplegia, instead of the paralysis being abrupt, many min- 
utes, or even hours, are required for its complete development, and 
during this time there is very great pain. Under these circum- 
stances the lesion is a hemorrhage outside of the cord into the 
spinal membranes. The rate of the development of the paralysis 

4 



50 DIAGNOSTIC NEUROLOGY. 

varies according to the amount and rapidity of the hemorrhage. 
The loss of power is due not to an immediate lesion of the cord, 
but to pressure upon the cord, and especially upon the motor-nerve 
roots, by the exuded blood. Unless the blood be in great amount 
and thrown out with excessive rapidity, the paralysis will grow 
more and more marked during several hours, and will ascend 
higher and higher. As the blood creeps up the spinal cord or 
forces its way downw^ard, it tears the membranes away from the 
cord, presses or stretches or perhaps tears the posterior, as well as 
the anterior, spinal roots, and produces by this irritation of the 
sensory nerve-roots shooting, tearing, or burning pains, with more 
or less marked loss of sensibility in the aifected parts. The anaes- 
thesia is usually not as complete or as abrupt as in cases of intra- 
spinal apoplexy. Nevertheless, if the clot be a large one the 
sensory palsy may be complete, and the zone between the anaes- 
thetic and the sensitive portions may be very narrow. The blad- 
der and rectum are very frequently paralyzed. Priapism or other 
evidences of genito-urinary irritation might naturally be expected, 
but I have never in my own cases seen them. 

Paraplegias of rapid or slow, but not of immediate, develop- 
ment, are best studied under two headings : first, those which are 
accompanied with excessive pain ; second, those in which there is 
no pain, or, at most, only moderate suffering. 

Painful Paraplegia. — In the so-called painful paraplegia the 
suffering is usually intense, is often worse at night, and, although 
it may be persistent, is at least in its exacerbations paroxysmal. 
The pains, which are described as stabbing, lightning-like, burn- 
ing, etc., take almost every conceivable form. They are fre- 
quently felt in the neighborhood of the rectum or along the 
urethra. Motility is generally very slowly lost. The paralysis 
may be accompanied by spasm, but almost invariably at last the 
muscles are relaxed. The knee-jerks, at first in many cases ex- 
aggerated, are finally abolished. Hyperaesthesia may exist in the 
beginning, but at last gives place to anaesthesia. Trophic changes 
usually come on early, and may be complete. 

In painful paraplegia the lesion is either a disease of the lower 
vertebrae or else a growth, usually sarcomatous or distinctly can- 
cerous, so situated as to involve the nerves in their emergence 



J\ 



PARALYSIS. 51 

from the sacrum. When the vertebrae themselves are affected, the 
disease is almost invariably cancerous. An aneurism by pressure 
upon the lower vertebrae may destroy them, and as the nerves 
become implicated the pressure produces symptoms somewhat 
resembling those caused by malignant growths. 

Non-Painful Paraplegia. — A paraplegia without excessive 
pain may be developed in the course of from one to six days : 
such cases constitute a group sufficiently marked to be studied 
together, and to be subdivided into several sub-groups. 

Of these, sub-group the first includes those cases which so 
nearly correspond to those described by Landry that they may be 
known as Landry^s palsy, or ascending paralysis. 

Ascending" Paralysis. — In some of the cases of ascending 
paralysis the symptoms are preceded by evidences of nervous dis- 
turbance, such as feelings of weakness, irregular formications, 
spots of numbness, weariness and discomfort, and possibly occa- 
sional spasmodic contractions. Either with or without these pro- 
dromes great weakness of the lower extremities comes on, and 
increases until, in the course of a few hours, standing or walking 
is impossible. 

The palsy usually appears first in the muscles of the foot, then 
in the legs, then in the thighs, until the whole leg is flaccid and 
without power. The symptoms steadily progress upward, in- 
volving soon the arms and finally the muscles of respiration, and 
in this way producing death. The temperature of the body is 
very rarely, if ever, above normal; but, according to Hammond, 
the affected limbs are distinctly lower in temperature than normal. 
The knee-jerk is in most cases diminished, and is not rarely in the 
latter stages of the attack abolished, but early in the paralysis, 
and even when voluntary motion is profoundly affected, it may be 
well preserved : neither the bladder nor the rectum is usually 
paralyzed. 

According to Landry, who first gave the name of ascending 
paralysis to cases of this character, the order in which the muscles 
are affected by the paralysis is, — 

First The muscles which move the toes and foot, then the 
posterior muscles of the thigh and pelvis, and lastly the anterior 
and internal muscles of the thigh. 

Second. The muscles which move the fingers, those which move 



52 DIAGNOSTIC NEUROLOGY. 

the haDcl, and the arm upon the scapula, and lastly the muscles 
which move the forearm upon the arm. 

Third. The muscles of the trunk. 

Fourth, The muscles of respiration, then those of the tongue, 
pharynx, and oesophagus. 

In many cases the paralysis does not follow the course laid 
down by Landry ; it is often more irregular, one arm or one leg 
being more paralyzed than the other; and cases are affirmed to 
have existed in which the symptoms began at the upper portion 
of the cord and ran rapidly downward, involving therefore the 
upper extremities first. It is stated by Levi {Archives Gen. de 
M6d.^ sixth series, vol. i., 1885, 129) that Cuvier died from an 
acute descending paralysis, affecting the medulla almost in the 
beginning of the attack. 

There is no pain during the whole attack, or at least nothing 
beyond discomfort, formications, or more or less distinct numb- 
ness. Usually cutaneous sensibility is not entirely destroyed ; 
sometimes it appears to be but little affected; but in a few cases 
there has been almost complete anaesthesia. There are usually no 
trophic changes, so that bed-sores, if they ever occur, are very 
rare. In a few cases of acute paraplegia of doubtful character 
perforating ulcers have appeared. QEdema of the skin was 
noted by Eisenlohr, and in some cases there has been a profuse 
secretion of sweat. In a case under my own care it was found 
by staining the nails with nitric acid that there was a partial I 
arrest of growth, which was much more marked in the most 
completely paralyzed portions of the body. 

A very important distinction which divides the cases of acute 11 
paraplegia just spoken of is that in some the symptoms pro- 
gress slowly, requiring several days for their full development, 
whilst in others the symptoms rapidly increase. It is uncertain 
whether there is a vital difference in the pathology of these cases, 
but clinically they differ, in that the symptoms when slowly de- 
veloped are prone to be arrested, so that the patient escapes for 
the time being, and in some instances entirely recovers. On the 
other hand, when the palsy rapidly rises up the body during the 
first twelve hours, it is rarely arrested, — the patient usually dying 
in a few days of asphyxia from respiratory palsy. 

A much more infrequent form of acute paraplegia than that 



PAEALYSIS. 53 

just described, and which is perhaps worthy of constituting a second 
sub-group of cases, is typified by a case reported by C. Eisen- 
lohr, in which, after exposure, a man was taken with pains in his 
limbs, followed by a rapidly-ascending paralysis, which became 
so complete that he could not move either his hands or his feet. 
There was fever, exaggerated knee-jerk, oedema of the extremi- 
ties, preservation of the normal electro-contractility of the mus- 
cles, and, after a few days, rapid recovery {Archiv f, Psychiatrie^ 
Bd. v., 219). 

Acute Central Myelitis. — In the second group of cases of 
acute paraplegia symptoms somewhat similar to those of ascend- 
ing palsy are present, but the following important differences are 
well marked : the anaesthesia is much more pronounced, and may 
be complete; paralysis of the bladder and rectum occurs early; 
the reflexes are soon abolished, and trophic changes take place 
almost at once in the paralyzed muscles, so that in the course of a 
very short time faradic contractility is lost and the reactions of 
degeneration appear; trophic changes in other than muscular 
tissue also occur early ; sloughing bed-sores, especially in the but- 
tocks and heels, soon appear, and rapidly increase ; oedema of the 
paralyzed parts occui^. Death in these cases may take place, as in 
acute ascending palsy, from implication of the muscles of respi- 
ration, but usually the patient dies from exhaustion, due in part 
to bed-sores.'^ 

This form of acute paraplegia is clearly separated from the 
other varieties by the rapid trophic changes. It constitutes the 
so-called acute central myelitis, an affection in which the central 
gray matter of the spinal cord is attacked : the ganglionic cells 
swell up, lose their processes, become granular in the interior, 
are converted into shapeless round masses, and finally disappear 
entirely ; whilst, at the same time, disintegration occurs in the tis- 
sue around them. (For cases, see Ross, Diseases of the Nervous 
System, also Wigglesworth, Liverpool 3Ied. Journ., July, 1885.) 

Lesions of Ascending Palsy, — In our first group of cases of 
acute paraplegia, the so-called ascending or Landry's palsy, a 
large number of post-mortem examinations have been made by 

■^ These cases will be more fully described in the next great group of para- 
plegias. See page 64. 



54 DIAGNOSTIC NEUROLOGY. 

trustworthy observers^ and the spinal cord has been examined 
most thoroughly, without any lesion being detected. We must, 
therefore, conclude that in the majority of these cases in which 
death occurs in a few days no lesions can be found in the spinal 
cord. In some cases, however, of ascending paralysis the white 
matter of the spinal cord has been found greatly altered. (See my 
own case. Therapeutic Gazette, 1885, also case reported by Hoff- 
mann, Archivfur Psychiatrie, 1884, p. 140.) In these cases of de- 
generation of the white matter the symptoms vary somewhat 
according to the tract of white matter which is especially attacked. 
The absence of muscular alteration is very well accounted for by 
the lack of change in the trophic ganglionic cells. Those cases 
of ascending paralysis in which no lesion of the spinal cord has 
been found may be theoretically accounted for by supposing that 
time has not elapsed for changes sufficiently gross to be recognized 
by the microscope to be produced. I do not think, however, that 
this can be accepted as a sufficient explanation of all the cases. 
It is probable that sometimes the symptoms are the result of a 
rheumatic* or other toxsemic arrest of function in the spinal cord, 
whilst I still believe that engorgement of the vast plexus of veins 
in the vertebral canal outside of the cord may cause an ascending 
paralysis. It is probably these cases of congestion that consti- 
tute the clinical group of ascending paralyses, in which the symp- 
toms fail to reach a fatal issue and recovery occurs. 

There are cases of ascending paralysis in which the symptoms 
seem to be half-way between those of group No. 1 and group No. 
2. These may be explained as cases of organic disease in which 
the lesion attacks both the white and the gray matter, — the char- 
acter of the symptoms varying as the white matter of the cord or 
the gray bears the brunt of the attack. 

It must also be remembered that in most of the cases of ascend- 
ing paralysis in which no lesion has been found the nerves were 
not examined, and that an inflammation or degeneration of the 
motor nerve may have existed in some of these cases ; especially 
as Dejeriue and Goetz have found in a case in which there was no 
demonstrable lesion in the spinal cord, changes in the anterior 



^ It seems to me very probable that such cases as those of Eisenlohr are 
rheumatic. 



PARALYSIS. 55 

nerve-roots similar to those of parenchymatous inflammation or 
degenerative atrophy, — changes which appear to be very similar in 
character to those which I found in the white matter of a cord in 
a case of Landry's paralysis. 

Multiple Neuritis. — There is a group of cases in which para- 
plegia may develop very rapidly and deepen into general palsy, 
with symptoms simulating those of true ascending paralysis, in 
which the lesion is an inflammation of the nerve-trunks. As 
much can be accomplished by treatment, it is very important to 
recognize the true nature of multiple neuritis. The disease may 
take a very acute form, with death in the course of a few days from 
paralysis of muscles essential to life, or it may run a prolonged 
subacute course. When recovery follows either the acute or the 
subacute form, more or less permanent structural change of the 
muscles may be left. In cases of a subacute type, instead of the 
symptoms simulating those of ascending paralysis, various discon- 
nected portions of the body may be affected, and a true multiple 
palsy, or a single or a double monoplegia, be produced. Certain 
cases of violent sciatica with rapid loss of power in the leg af- 
ford instances of monoplegia from inflammation of a nerve-trunk, 
and I have seen a severe subacute multiple neuritis, with all 
the characteristic symptoms confined to the arms, producing a 
double brachial monoplegia. The clinical evidence shows that 
any nerve of the body or any combinations of nerves may be 
affected by a neuritis. 

In a very large proportion of the cases acute general multiple 
neuritis has followed excessive exposure, and not rarely the ex- 
posure has been associated with extraordinary physical exertion. 
In many cases the disease seems to be rheumatic. Leyden asserts 
that the salicylates act remarkably well, — a statement which I 
can confirm from experience. Ordinary sciatica is very closely 
related to multiple neuritis. Usually, but not always, in sciatica, 
as in other forms of neuritis, the sensory filaments of the nerve 
are chiefly attacked ; but it will be shown later that it is probable 
that inflammation of the motor filaments of nerves may occur 
without the afferent or sensory fibres being distinctly influenced. 

Although multiple neuritis is often of rheumatic origin, it is 
not invariably so. It is especially frequent in persons who use 
alcohol in excess, and not rarely follows various infectious diseases 



66 DIAGNOSTIC NEUROLOGY. 

of a low type. The so-called diphtheritic paralysis is due to 
a multiple neuritis. The loss of power which may follow 
typhoid fever (see page 43) has, at least in some cases, similar 
origin. Lowenfeld has seen multiple neuritis after recurrrent 
fever and after erysipelas, whilst Dejerine has noted it in syphi- 
litics, and its presence in the Japanese disease beriberi has been 
fully established. 

Malignant Multiple Neuritis. — In the acute forms of multiple 
neuritis the constitutional symptoms may be very severe, and 
marked by great prostration and high fever. The onset is often 
very sudden, but may be more gradual. The loss of power may 
be pronounced within twenty-four hours. It usually begins and 
develops symmetrically in two, and sometimes in all four, of the 
extremities ; but perhaps in the majority of cases the arms are the 
more urgently attacked. The muscles of the hands and forearms 
and those of the leg proper are the first to lose their power. Rap- 
idly, however, the palsy creeps towards the trunk, and passes (in 
some cases) to the muscles of the face. Double vision may develop 
as the result of paralysis of the eye-muscles. Speech and swallow- 
ing become involved, and as the respiratory muscles fail in power 
the patient sinks into a fatal asphyxia. 

The heart may be aifected, and degeneration of its nerves and 
muscular fibres has been detected. The sudden syncopal deaths 
which sometimes occur after diphtheria probably have this origin. 
Sometimes preceding and sometimes immediately following the 
motor symptoms great disturbances of sensation appear. Violent 
rheumatic-like pains occur in the limbs, or fulgurant agonies 
shoot up and down the nerve-trunks. Formications, — a peculiar 
feeling of numbness, — all forms of parsesthesise, — may be present. 
Hypersesthesia often accompanies the first stages of the disorder, 
but in advancing cases it is followed by anaesthesia, which may 
be a true ancesthesia dolorosa. (See section on Anaesthesia.) An 
almost pathognomonic symptom is anaesthesia of the skin, asso- 
ciated with excessive sensitiveness of the muscles and other struc- 
tures reached by deep pressure. All kinds of sensation seem to 
be affected : not only does the patient fail to recognize the points of 
the aesthesiometer, but scratching, or finally even pinching, pro- 
duces no pain, and heat and cold elicit no response. Dreschfeld 
and Ley den have noted a very pronounced girdle sensation, which 



PARALYSIS. 57 

the first-named observer, with probable accuracy, believes to be the 
result of the inflammation of the trunkal nerves. The trigeminal 
nerve usually escapes ; but two cases in which it was attacked have 
been reported by Lowenfeld [Neurol, Centralb., 1885, p. 140). 
Pain on movement may be present, soreness of the muscles is 
often noted, but marked tenderness of the nerve-trunks upon 
pressure is pathognomonic. In a few cases the nerves of special 
senses have been attacked, and partial blindness and deafness 
have been noticed. 

In marked cases of acute multiple neuritis the trophic changes 
are pronounced. In the course of a very few days, or even hours, 
the affected muscles begin to waste. Brenner and Bernhardt state 
that there is usually lowering of the electro-excitability of the 
muscles, and not a qualitative alteration ; but cases have been re- 
ported in which there have been true reactions of degeneration. 
(See chapter on Trophic Changes.) The paralyzed muscle is flaccid 
and soft, the absence of contractures is characteristic, but in very 
old cases deformities from contractures of the normal antagonistic 
muscles may be present. Even late contractures of the paralyzed 
muscles are usually held to indicate the presence of some second- 
ary disorder of the nerve-centres; but this seems to me doubtful. 
(See G. H. Roger, L^Encephale, 1885, p. 140.) Trophic changes 
in other than the muscular tissues are not rare, such as pigmen- 
tation and thickening of the skin, eczematous eruptions, altera- 
tions of the nails, oedema, bed-sores, etc. A peculiar lividity of 
the affected extremities, due to vaso-motor weakness, has been 
much commented on. 

Very early in acute multiple neuritis the knee-jerk disappears, 
but the superficial skin reflexes, such as that of tickling, may first 
be exaggerated, and for a long time remain fully as active as 
normal ; finally, however, they too diminish. The sphincters 
rarely are attacked, although Leyden reports one case in which 
the bladder was affected. 

The diagnosis of cases of multiple neuritis conforming to the 
type just detailed is easy. The combination of paralysis with 
atrophy of the muscle, excessive disturbances of sensation, and 
tenderness of the nerve-trunks marks the disorder at once. On 
the other hand, the recognition of some of the subacute forms of 
multiple neuritis is diflScult. 



58 DIAGNOSTIC NEUROLOGY. 

The paralysis of acute multiple neuritis is caused by a number 
of distinct lesions^ and is therefore a true multiple palsy, although 
it may simulate a paraplegia or a general palsy. Not rarely, 
however, the neuritis is limited to certain nerve-regions, as the 
brachial plexus, or even to a single nerve. In this way monoplegia 
and local palsies are produced. The course of such an affection 
may be very rapid, but usually it is subacute. Although this 
subacute multiple neuritis ought perhaps to be considered under 
the heading of Multiple Palsies, for convenience I shall discuss 
it here. 

Subacute Multiple Neuritis. — The symptoms of the subacute 
cases of multiple neuritis may differ from those of the acute dis- 
ease only in being more confined in their seat and less rapid in 
their course. In other cases the symptoms are in the subacute 
affections very different from those of the acute disorder. Thus, 
Leyden, Lowenfeld, and others have noticed as a first symp- 
tom in some cases a loss of co-ordinating power, producing a well- 
marked ataxic gait. Whenever in any case of multiple palsy 
there are marked disturbances of sensation and tenderness of the 
nerve-trunk on pressure, the diagnosis is sufficiently made out, 
even though the trophic changes come very slowly. 

Diagnosis of Multiple Neuritis. — Although the diagnosis of 
a typical multiple neuritis is very easy, it is otherwise with aber- 
rant forms. Thus, in the case recorded by H. Mieth {Deutsche 
Med, Wochen., 1885) there was paralysis, with diminished reflexes 
and great difficulty of swallowing and of speech, without trophic 
changes in the muscles or in the tissues, and without distinct dis- 
turbances of sensation. It is well known that sciatica may occur 
without pronounced palsy or rapid wasting of the muscles, evi- 
dence that the sensory nerve-filaments may be attacked without 
serious involvement of the motor fibres, and it is probable that in 
cases like that reported by Mieth the motor filaments of the 
nerves are affected without the sensory being distinctly implicated. 
Desuos and Joffroy, indeed (quoted by G. H. Roger, L^Encephaley 
1885, 140), have proved, by post-mortem examination of a case 
where there had been no distinct disturbances of sensation, that 
this non-sensory multiple neuritis does occur. As Bernhardt says, 
the diagnosis between this affection and poliomyelitis becomes 
excessively difficult. 



PARALYSIS. 59 

The matter is made more troublesome by the fact (cases, Pitres, 
Archiv de Neurol,^ Bd. vi., 180) that in locomotor ataxia, in acute 
myelitis, and probably in all spinal diseases, the peripheral 
nerves occasionally undergo acute degeneration. There is, there- 
fore, a descending as well as an ascending neuritis ; and whenever 
there is found at an autopsy a degeneration both of the spinal cord 
and of the nerve-trunks, the question arises whether the original 
lesion was peripheral and centripetal or centric and centrifugal. 
In very few cases of the ascending palsy have the peripheral 
nerves been properly studied. Indeed, it is probable that the 
lesion of the cord which was found in the case reported by Dr. 
Dercum and myself was the result of an overlooked ascending 
neuritis. 

It is not probable that a multiple neuritis can exist without 
the sensory filaments being at least so far implicated as to cause 
tenderness of the nerve-trunks, and in the absence of positive 
clinical evidence we must consider that the diagnosis between a 
multiple neuritis and a poliomyelitis can be made by pressing 
upon the nerve-trunks. It is possible, however, that the future 
may reveal the existence of a pure motor neuritis, and it is ex- 
ceedingly important that observers should note in doubtful cases 
whether the nerve-trunks are or are not tender. Literature 
should not be further encumbered with reports of cases without 
autopsies, or with imperfect autopsies. 

Reactions of Degeneration in Neuritis. — It has been stated by 
various observers that true reactions of degeneration are never 
to be obtained in the atrophied muscles of multiple neuritis ; but 
this is undoubtedly an error, as I know from my own experience, 
which is confirmed by Dr. L. Lowenfeld ( Ueher Multiple Neuritis, 
Munich, 1885) and by Professor Lancereaux {Union Med., July, 
1885). Without doubt, however, as Bernhardt (Verhandl. Int. 
Congr., 1884) states, the changes of electrical reactions come on 
less rapidly in multiple neuritis than they do in poliomyelitis. 
Professor Remak considers that the localization of the palsy is of 
diagnostic importance, between the two diseases ; but in this he 
is not borne out by the clinical records. 

Alcoholic Spinal Paralysis. — Under the head of alcoholic 
spinal paralysis Dr. H. Broadbent {Medico- Chir. Trans., vol. 
Ixvii.) has reported a form of disease which is probably alcoholic 



60 DIAGNOSTIC NEUROLOGY. 

multiple neuritis. Indeed, the abuse of alcohol seems to be a very- 
important etiological factor in multiple neuritis. Cases similar to 
those of Broadbent have been reported by Lancereaux and others. 
They vary considerably in their features. There is at first grad- 
ually-increasing weakness of the lower extremities, when sud- 
denly marked loss of power becomes manifest in the extensor 
muscles of the forearm, giving rise to double wrist-drop. The 
flexors of the hand may be affected very early. Usually, some- 
what later they become paralyzed, so that the hand is like a flail. 
Although the patient can walk and the movements of the elbow 
and shoulder are vigorous, the paralysis rapidly advances, until 
all four extremities are almost completely motionless, the arms, as 
a rule, being more seriously implicated than the legs. The re- 
flexes are abolished. There is usually no pain, though the 
muscles may be tender on handling, and the sphincters retain 
their functional power. In one of Dr. Broadbent's cases, how- 
ever, sharp pains shot down the legs, and there was inconti- 
nence of urine. In the course of a very few days the muscles of 
the trunk become implicated, and the patient dies of paralysis of 
respiration, precisely as in ascending palsy. Loss of tone in the 
capillaries, with consequent livid congestion of dependent parts, is 
said to be diagnostic of this form of paralysis. Careful exami- 
nation of the spinal cord failed to detect any lesions. The cases 
are said to be much more frequent in women than in men. 

Subacute Paraplegia. 

The second group of organic paraplegias comprise those cases 
in which the paralysis develops so slowly as to require many days 
or weeks, but not months, for the symptoms to become very pro- 
nounced. In this group are included cases of transverse myelitis 
and of general myelitis. It must be remembered that in excep- 
tional cases either of these affections may develop with phenomenal 
rapidity and give origin to an acute paraplegia. 

Transverse Myelitis. — Transverse or compression myelitis is 
invariably the result of disease of the vertebrae or of the mem- 
branes of the cord. The most frequent cause is scrofulous or 
syphilitic degeneration of the vertebrae; but syphilitic, cancerous, 
or other tumors may produce the disease. 



PARALYSIS. 61 

In the majority of cases local pains precede the development 
of those symptoms which are directly due to the myelitis. The 
seat of these pains varies according to the seat of the disease, — the 
rule being that the pains are in the distribution of those nerves 
whose roots pass through the inflamed or degenerated vertebral 
tissues. Along with these symptoms of irritation of the posterior 
spinal roots there may be cramps or convulsive movements, evi- 
dences that anterior or motor nerve-roots are implicated : except 
in very rare instances, these motor symptoms are much less marked 
than is the sensory disturbance. 

When the cause of a transverse myelitis is cancer, the pain is 
generally atrocious, radiates in all directions along the trunks 
of the nerves, is described as shooting and tearing and burning, 
and is usually associated with very pronounced hypersesthesia of 
the skin. The pangs themselves are paroxysmal in violence, 
although present, to some extent, the whole time. The crises 
of the paroxysms are said by Grasset to occur almost invariably 
at night. They are increased by any attempt at motion, and 
seem at times to be brought on by slight touches. Hyperses- 
thesia in these cases is often finally replaced by anaesthesia with- 
out the pains being relieved, and herpetic eruptions appear along 
the courses of various nerves. In its acute form this affection 
is the painful paraplegia, or paraplegia dolorosa, already de- 
scribed (see page 50). Painful paraplegia may also be due to 
cancerous tumors outside of the spinal column, so situated in the 
neighborhood of the sacrum as to involve the numerous nerves 
coming from the cauda equina. The pain may precede the palsy 
by a considerable time. I have known it to be the first symptom 
of pelvic cancer. 

The symptoms directly due to the transverse myelitis itself are 
most marked in regard to motion. Voluntary power is finally 
lost ; the reflexes are exaggerated, but not to the degree seen in 
cases of general myelitis, except when secondary spinal lesions 
have followed upon the transverse myelitis. 

In the latter stages of transverse myelitis there is always para- 
plegia, but in the beginning, if the inflammation be more intense 
on one side of the spinal cord than on the other, one extremity 
may be more profoundly affected than another, and a brachial or 
crural monoplegia or even an apparent hemiplegia may be present. 



62 DIAGNOSTIC NEUROLOGY. 

Close inspection will, however, almost always detect some weak- 
ness of the leg at first thought to be intact. When the transverse 
myelitis is high up in the cord, the arms may be affected before 
the legs. 

Sensibility in transverse myelitis at first is dulled, but finally 
it is completely lost. Paralysis of the bladder and rectum occurs, 
and in many cases the symptoms finally are not to be distinguished 
from those of a more general subacute myelitis. Indeed, a sub- 
acute myelitis may very well be developed out of a transverse 
myelitis. 

Early Diagnosis of Transverse Myelitis, — It is a matter of the 
greatest importance to recognize early the presence of vertebral 
inflammation, especially when the latter is of a scrofulous char- 
acter. By paying attention to the pain this can frequently be done 
before the occurrence of a transverse myelitis, or the appearance 
of any striking local evidences of disease of the vertebrae. This 
is especially true when the disease is located in the upper dorsal or 
the lower cervical region. Whenever a patient with the aspect of 
a person suffering from severe disease has, without obvious cause, 
an intense fixed pain about the shoulders or in the arms, it should 
be borne in mind that this pain may be due to irritation of nerve- 
roots caused by incipient disease of the vertebrae or of the spinal 
membranes. When other causes for such pain can be excluded, 
and deep pressure over the spine produces pain, or pain can be 
caused by jars of the spinal column, or by blows upon the top of 
the head directed downward, the diagnosis is sufficiently probable 
for therapeutic purposes. Some aid may be gained by the appli- 
cation of RosenthaVs test, upon which, however, in my experience, 
not much reliance can be placed. The test is made by placing 
one pole of a faradic battery in contact with the front of the 
body, and passing the other pole down the centre of the vertebral 
column, when, if any inflammatory lesion exists, pain will be de- 
veloped at the seat of the change. Unfortunately, tenderness 
may often be found when there is no vertebral disease, and, if the 
anterior portions of the vertebrae alone be implicated, pain may 
not be elicited by the current. 

Care may at times be necessary not to confound incipient ver- 
tebral disease with the so-called spinal ancemia or spinal irritation 
(see article on Pain) ; but the aspect, mode of talking, and general 



PARALYSIS. 63 

conduct of the patients are so different in the two diseases that the 
experienced physician can hardly be misled, although these differ- 
ences may be very hard to put in words. Moreover, in spinal irri- 
tation there is intense tenderness to the slightest touch, whilst in 
the early stages of true vertebral disease tenderness is evoked only 
by firm pressure. Further, the distant pains of spinal irritation lack 
the fixedness and intensity so characteristic of vertebral disease. 

It must be borne in mind that a syphilitic or other growth 
springing from the membranes of the cord may involve the nerve- 
roots, and may produce transverse myelitis, with early symptoms 
very like those of vertebral caries. Deep vertebral tenderness 
under these circumstances develops only late in the disease, when 
the bodies of the vertebrae are affected, although hypersesthesia 
over the vertebral column, as over other parts of the body, may be 
caused by a secondary neuritis. 

Cervical Pachymening'itis. — A class of rare cases which are 
especially liable to be confounded in their first stages with in- 
cipient Pott's disease, and in their latter stages with organic dis- 
ease of the spinal cord itself, is contained in cervical pachy- 
meningitis, an affection whose history was especially elaborated by 
Charcot and Joffroy. This disease is, indeed, in its latter stages 
accompanied by a transverse myelitis, and many of the symptoms 
which are at such time present are due to the transverse myelitis. 
In the first stage there is vague pain in the neck and in the occipital 
region of the head, which is exaggerated by pressure and move- 
ments and is associated with more or less marked spasm of the 
muscles of the neck. Frequently there are paroxysms of pain 
associated with temporary torticollis. These symptoms slowly in- 
crease, often for from two to five or six months, until, at last, the 
suffering is very great, especially at night, and in irregular parox- 
ysms, whilst immobility of the neck from spasm becomes com- 
plete. Radiating pangs shoot along the nerves of the neck into 
the arms, back, and head, and hypersesthesia and fulgurating 
pains often occur in the hands. In some cases the pain in the 
neck is not at all marked, whilst the peripheral pains are excessively 
violent. Digestive disturbance and vomiting are not rare. As 
the disease increases, paralysis appears usually first in the arms ; 
sometimes, however, it is distinctly paraplegic in type, and in 
some cases even hemiplegic. 



64 DIAGNOSTIC NEUROLOGY. 

Subacute Central Myelitis. — Among the cases of subacute 
paraplegias belong many of the cases of central myelitis. In this 
disease, with or without prodromes, the patient is taken with a 
fever, which may be preceded by a chill and be accompanied by 
much sweating. Pains of greater or less severity are felt in the 
legs and in the lumbar regions. These rapidly increase, and may 
take a girdle form. Power is also rapidly lost in the legs, but at 
the same time spasmodic jerkings and irregular muscular con- 
tractions are developed. In very rapid cases in the course of two 
or three days the paraplegia may be almost complete, and death 
has occurred as early as the fifth day. The reflexes are exagger- 
ated, but before death may be weakened and finally abolished. 
Paralysis of the bladder early appears. The urine has to be drawn 
off by a catheter, and is strongly ammoniacal. Large eschars now 
form upon the buttocks, or upon the heels where they rest upon the 
bed. These rapidly increase, and add greatly to the exhaustion 
of the patient. Sensibility, usually less early affected than motion, 
soon, however, becomes blunted, and at last there may be com- 
plete anaesthesia. The symptoms which have just been mentioned 
constitute a typical case of a general acute myelitis, and may be 
developed so rapidly as to put the case in the group of acute 
paraplegias. 

In some instances of myelitis the evidences of motor and sen- 
sory excitement are more marked than has been indicated, the ir- 
regular muscular contractions are associated with an almost tetanic 
rigidity of the muscles of the trunk and of the limbs, and along 
with the pain there is marked hyperaesthesia. If the myelitis 
attack the upper dorsal region, the symptoms in the arms may 
be even more pronounced than those in the legs, and cough, 
with marked dyspnoea, may be prominent. Gastric crises with 
violent vomiting may be very distressing, and may simulate in 
their severity those of locomotor ataxia. The difficulty of swal- 
lowing is often very great. If the cervical region be affected, 
irregular dilatation or contraction of the pupils may be pro- 
duced ; and a very prominent symptom in some cases has been an 
extraordinary reduction of the pulse, which has been noted to 
fall as low as 28 per minute. 



PARALYSIS. 65 



CHKONIC PARAPLEGIA. 



Chronic paraplegia (group three of my arrangement) includes 
those cases in which many weeks^ months, or years are required 
for the full development of the symptoms. In arriving at a 
diagnosis in these cases, sensation, the condition of the bladder, 
and the state of the muscular system are especially to be studied. 

There are two diseases which are common causes of chronic 
paraplegia. This does not include cases of multiple palsy, which, 
as already stated, when located especially in the lower legs, may 
give rise to an apparent paraplegia, and may pursue a chronic 
course. The nature of these cases can almost always be recog- 
nized by the irregularities in the development of the palsy, and by 
the wasting of the aflFected muscles, conjoined with the absence of 
the symptoms of chronic general myelitis. (See page 58.) 

Both in chronic myelitis and in sclerosis the symptoms vary 
according to the region of the cord attacked; but in sclerosis 
with motor paralysis distinct disturbances of sensation, as well 
as paralysis of the bladder or of the rectum, are extremely rare. 

Chronic Myelitis. — In chronic myelitis anaesthesia is present 
only in exceptional cases, and still more rarely is it preceded by 
hypersesthesia. Very seldom is there severe pain, although formi- 
cations and parsesthesia are frequent. When the disturbances of 
sensation are marked, the whole of the structure of the cord must 
be considered as implicated. Trophic changes may occur in the 
muscles and other tissues, but it is remarkable how frequently the 
trophic cells of the gray matter escape, even when all the rest 
of the cord is attacked. In the beginning of the disease the 
reflexes may be increased, to be finally abolished. 

There is a form of chronic myelitis in which the reflexes re- 
main exaggerated for many months, and in some of these cases 
they are grossly exaggerated, and a certain amount of tonic spas- 
modic contraction exists in the affected muscle ; but the rigidity 
does not compare with that which is seen in the sclerotic form of 
paraplegia. On the other hand, irregular spontaneous jerkings of 
the leg, spasmodic twitchings of the muscles, and painful contrac- 
tions at night are more frequent in myelitis than in sclerosis. 
Girdle Sensation, — A very important symptom which is present 



66 DIAGNOSTIC NEUROLOGY. 

in both forms of chronic paraplegia is tlie girdle sensation, usually 
felt in the abdomen, but in some cases very distinct at a lower or 
higher position in the legs. Its seat is probably connected with 
the position of the disease in the spinal cord. 

In chronic myelitis the patient walks slowly, dragging the feet 
with evident effort. The posture does not essentially differ from 
the norm, there are rarely bizarre movements of the legs, and 
any tottering or unsteadiness is evidently from feebleness. 

Spasmodic Tabes. — When, in a case of chronic paraplegia 
developed during adult life, the muscles of the leg are exceedingly 
rigid, firmly contracted, with their tendons projecting and hard, and 
the legs and feet are more or less distorted, the patient is suffering 
from spasmodic tabes. In the early stages of this affection the 
patients complain that they are readily fatigued, and that their 
gait is dragging. Even before there is distinct loss of power 
the patient will be troubled at night, especially after a hard 
day's march, with clonic or tonic spasms, which cause the legs 
to stiffen suddenly or to be jerked about. A little later the 
stiffness and loss of power combine to produce a very character- 
istic gait. The contractures of the various muscles prevent 
the bending of the joints of the knee and hip, whilst the great 
power of the muscles of the calf tends to draw the heel up and 
to thrust the toe downward. Consequently, the foot can be lifted 
suflSciently from the ground to make a step only by raising and 
rotating the pelvis so that the body is inclined towards the leg 
upon which the patient rests during the step, whilst the moving 
foot is slowly thrust forward. The toes appear to stick to the 
ground, and are only with the greatest difficulty sufficiently raised 
to be pushed forward. The steps are of necessity very short, — it 
may be only three or four inches. As the leg is put forward, not 
rarely violent tremblings affect it, and in some cases these move- 
ments are so rhythmical as to throw the heels of the patient up 
and down in regular vibrations. As the disease progresses, the 
contractures of the muscles of the calf become so great that the 
heels are permanently drawn from the ground, and the patient 
rests upon the toes. Under these circumstances the trunk is of 
necessity thrown forward, and is preserved from falling only by 
means of crutches or canes held well in advance of the body. A 
little later than this all power of locomotion is lost, and not 



PARALYSIS. 67 

rarely the patient is confined to bed, or, if he attempts to sit, must 
be propped up in a chair, with his feet supported in front of him. 

When the power of locomotion is lost, the leg is usually flexed 
upon the thigh, the heel drawn up, and the toes turned inward, 
these positions being due to the superior power of the posterior 
muscles of the thigh and leg and of the abductor muscles as 
compared with their antagonists. In some cases the patient lies 
with the legs stiffly extended, very rigid, the feet inverted and 
often crossed. The bladder and rectum are not aflFected. In 
most cases of spasmodic tabes the muscles do not undergo wasting, 
and their electrical reactions are not altered in quality, and are 
even more sensitive than normal. The spinal lesion in spasmodic 
tabes is sclerosis of the lateral columns, usually known as lateral 
sclerosis. 

Amyotrophic Lateral Sclerosis. — In certain cases of spas- 
modic tabes the muscles are very much wasted, and may finally 
disappear (see chapter on Trophic Changes), although their elec- 
trical reactions are exceedingly slow to alter. These are instances 
of the so-called amyotrophic lateral sclerosis, in which the lateral 
columns and the large multipolar cells of the adjacent gray matter 
are simultaneously diseased. Frequently in these cases the 
wasting of the various muscles is irregular and unequal, so that 
the case presents the aspect of a multiple palsy attacking a person 
already affected with disease of the lateral column ; but in some 
instances the trophic changes Aev^lo^p pari passu with the paralysis. 

Multiple Spinal Sclerosis. — When the symptoms of spas- 
modic tabes are associated with more or less irregularly developed 
disturbances of sensation similar to those of locomotor ataxia, 
disseminated sclerosis will be found after death ; that is, patches 
of sclerosis, irregular in size, shape, and seat, are scattered through 
the cord. The symptoms in such cases vary as the lesions pre- 
dominate in one or other of the spinal tracts. 

MONOPLEGIA. 

A monoplegia is a paralysis of one extremity. When of the 
arm, it is spoken of as brachial monoplegia ; w^hen of the leg, as 
crural monoplegia. 

Hysterical Monoplegia. — Hysterical monoplegia is rare, but 



68 DIAGNOSTIC NEUROLOGY. 

may occur^ and is not infrequently attributed to a real or an al- 
leged injury. Under such circumstances the true nature of the loss 
of power is apt to be overlooked. If contractures come on imme- 
diately after a real or an alleged injury, the paralysis is probably 
hysterical; but complete relaxation may exist in an hysterical 
monoplegia. When after a traumatism the paralysis and the 
relaxation are complete and there is no wasting of the muscles, 
the affection is usually hysterical, since in all cases of total or 
nearly total loss of power from injuries to a nerve the muscles 
rapidly change. Irregularities in the anatomical relations between 
the disturbances of sensibility and the alterations of mobility in- 
dicate an hysterical origin, but these relations may, in hysteria, 
conform to the organic type. 

Irregularity of Impliccdion of Muscles, — An organic mono- 
plegia may be looked upon as a collection of local palsies: thus, 
in a case of centric brachial monoplegia (see page 72) the cortical 
nerve-centres which preside over the various groups of muscles 
in the arm are located so near to one another that they are in- 
volved in a common, wide-reaching clot or other lesion; and in a 
peripheral brachial monoplegia many distinct nerve-trunks or 
many distinct groups of spinal ganglionic cells are involved. It 
is owing to these facts that the intensity of the palsy in brachial 
monoplegia varies in the different groups of arm-muscles accord- 
ing as one centre or the other is more implicated in the lesion. 

Double Monoplegia. — Two monoplegias may coexist in the same 
patient, and, when they happen to be on the same side of the 
body, may simulate a hemiplegia. The distinction, however, be- 
tween such a double monoplegia and a hemiplegia may be vital. 
In a double monoplegia there are necessarily two lesions, whilst in 
a hemiplegia the paralysis is the result of a single lesion. When 
an enormous clot upon the brain-surface affects the whole motor 
zone, it gives rise to a paralysis which must be considered a hemi- 
plegia. 

A monoplegia may be due to a lesion of a nerve, or of the large 
multipolar cells in the anterior cornua of the spinal cord, or of the 
brain-cortex. In making the diagnosis in any case the general 
situation of the lesion is first to be determined. 

Varieties of Monoplegia, — There is nothing in the paralyzed 
muscles which distinguishes a palsy due to a disease of the ante- 



PARALYSIS. 69 

rior spinal cornua from one which is the result of an aflPection of 
the nerves. These two classes of cases are for the purposes of 
diagnostic discussion profitably grouped together as peripheral 
palsies. Paralyses due to lesions of the brain-cortex are readily 
distinguished from peripheral palsies by a study of the affected 
muscles. Cerebral paralyses, therefore, constitute a second group 
of monoplegias, which may be spoken of as centric palsies. It 
must, however, be remembered that a nerve-trunk may be para- 
lyzed by a lesion within the cranium and yet the palsy belong to 
the peripheral group. Thus, if by an organic change in the pons 
or in the medulla, or by an exudation or a tumor at the base of 
the brain, the integrity of one of the cranial nerves be interfered 
with, the results are palsy and structural changes identical with 
those which would follow section of such nerve after its emer- 
gence from the cranium. 

An acute peripheral paralysis is always to be distinguished from 
a centric palsy by the rapid occurrence of structural changes in 
affected muscles, — changes the nature of which will be fully dis- 
cussed in the chapter on Trophic Alterations, to which the reader 
is referred for details. Suffice it for the present to state that 
in centric palsy the muscle does not undergo change, whilst in 
peripheral palsies the muscle in three or four days after the in- 
ception of the lesion begins to lose its power of responding to a 
rapidly-interrupted faradic current, and in the course of a week 
or two sensibly wastes. 

Anatomy of the Cortex, — In order to understand the produc- 
tion and diagnosis of cerebral monoplegias it is necessary to pay 
attention to the following considerations. The ganglionic cells 
of the brain-cortex, which originate the impulses that call forth 
voluntary movements, are scattered over a considerable portion 
of the cortex, so that a lesion may very readily affect some of 
the cells without influencing others. The nerve-fibres which pass 
downward from these cortical centres are, however, gathered 
together into a fasciculus so small that a lesion affecting one por- 
tion of the fibres almost invariably exerts a greater or less in- 
fluence upon the remainder. For these reasons centric or brain 
monoplegias are of cortical origin. It frequently happens in a 
hemiplegia that the arm or the leg is more affected than is its co- 
sufferer, because the clot presses more severely upon one portion 



70 



DIAGNOSTIC NEUROLOGY. 



of the conducting fasciculus in the brain than upon another. It 
is, however, excessively rare for a single set of fibres of this fas- 
ciculus to be affected by itself, and a monoplegia to be thus pro- 
duced. 

Fig. 3. 




For the purposes of diagnosis the cortical structure of the 
cerebrum may be divided into three portions. That which in 
diagram No. 3 lies in front of the letter A, Fig. 5, comprising the 



Fig. 4. 




so-called frontal convolutions, is the inert zone. Extensive lesions 
may exist in this portion of the brain and produce no symptoms 
whatever. The region between letters A and B comprises the 



PARALYSIS. 



71 



motor zone of the brain, extending as far downward as the fissure 
of Sylvius. The cortical region posterior to the letter B may be 
considered as chiefly sensory in its function. 

The motor zone of the cerebral cortex is composed of the an- 
terior central convolution (ascending frontal convolution), the 



Fig. 5. 



Fissure oj Rolands 




F*»stur« Bj SylVtUS 



posterior central convolution (ascending parietal convolution), 
and the paracentral lobule, and appears in some cases to reach 
into the lobulus quadratus, the supra-marginal convolution, and 
even the gyrus fornicatus. According to the collection of cases 
made by Exner, the extent of this zone is usually greater in the 
left than in the right hemisphere. The cortical cells, which are 
situated in the motor zone, appear to be more or less imperfectly 
grouped together, so that those muscles which are anatomically 
closely related to one another and habitually act together receive 
their impulse from contiguous cortical cells. 

Various attempts have been made to isolate and locate these 
groups by the study of the recorded cases in which the symptoms 
have been observed during life and the lesion after death. There 
appears to be a certain amount of uniformity in the position of 
the arm-, leg-, and face-centres, but this uniformity is not rarely 
departed from. It is very clear that the groups overlap one 
another. It may be asserted, as a general rule, that the anterior 
central convolution is more active as a motor centre than is the 



72 DIAGNOSTIC NEUBOLOGY. 

posterior central convolution, and that the cells which are con- 
nected with the lower extremities are situated in the upper por- 
tion of these convolutions, with the arm-centres below them and 
the centres connected with the face chiefly located in the anterior 
central convolution close to its foot. 

Exner arrives at the conclusion that the cortical arm-centres 
occupy the paracentral lobule, the anterior central convolution 
with the exception of its lowest portion, and the upper half of 
the posterior central convolution, reaching, in rare cases, into the 
lobulus quadratus and the gyrus fornicatus. The field of the lower 
extremity he locates in the paracentral lobule, the upper third 
of the anterior central convolution, and some portions of the 
upper third of the posterior central convolution. In rare cases, 
this field seems also to enter the lobulus quadratus (especially in 
the left hemisphere, in which it may even reach the cuneus). 

The facial nerve zone, according to Exner, occupies the lower 
half of the anterior central convolution and the lower third of 
the posterior central convolution. The centre for the tongue is 
in the foot of the anterior central convolution, although there is 
at least one case on record in which a lesion in the supra-marginal 
convolution produced hypoglossal symptoms. 



Cerebral Monoplegia. 



Abrupt Cerebral Monoplegia. — Sudden monoplegia of cere- 
bral origin may be due to traumatisms, to hemorrhage, and to 
arrest of the circulation by thrombi or embolisms. There are no 
known symptoms which enable us to decide whether the cause of 
a sudden brain-monoplegia is a hemorrhage or an arrest of circu- 
lation. 

Pro^essive Cerebral Monoplegia. — A cerebral monoplegia 
may be developed suddenly or gradually. When it comes on 
slowly it is due to a progressive lesion situated in the motor zone 
of the cortex. Such a lesion is of the nature of a tumor, of an 
outgrowth from the skull, or of a localized meningitis with much 
exudation or great disturbance of the circulation. It must be 
remembered that the cortical layer of the brain is supplied by 
blood-vessels which pass from the membranes into the brain- 
substance, and are, in the cortex, terminal arteries which do not 



1 



PARALYSIS. 73 

anastomose. Any change in the membranes may, by producing 
pressure upon the blood-vessels, interfere so seriously with the 
circulation in the cortical substance of the brain as to cause pro- 
gressive degeneration resulting in loss of function without there 
being a direct propagation of disease from the membranes to 
the brain-substance. In syphilitic meningitis the lesion has a 
very distinct tendency to invade the contiguous brain-substance. 
Syphilitic disease also much more frequently locates itself in 
the motor zone than do benign tumors : consequently, in a very 
large proportion of the cases of progressive cerebral monoplegia 
the lesion is a local syphilitic meningitis. 

Peripheral Monoplegia. 

Monoplegia from Pressure on Nerve. — Very frequently a 
man will awaken from a drunken stupor to find that his arm is 
paralyzed ; and it is common for a young bridegroom to get up 
in the morning with his arm in a similar condition. In either 
case pressure of a head upon the arm has been the cause of the 
trouble. The loss of motor power in these cases may be more or 
less complete ; there is usually tingling and a distinct feeling of 
deadness, but pronounced anaesthesia is very rare, although it may 
occur. The musculo-spiral nerve, on account of the manner in 
which it winds around the arm, is especially apt to suffer, and, as it 
chiefly supplies the extensors of the forearm, these muscles are 
usually most severely affected. A not rare form of pressure-palsy 
is the so-called crutch-palsy, in which a double or single mono- 
plegia is produced by the pressure of the crutches or crutch upon 
the nerves in the axilla. Pressure-palsy in most cases yields 
readily to treatment, and is rarely, if ever, sufficient to produce 
trophic changes. 

Monopleg-ia from Injury or Disease of Nerves.^ — Complete 
palsy of the arm may result from injuries to the brachial plexus, 
as well as from multiple neuritis or other idiopathic diseases of 
the same, and from affections of the cervical spinal cord which 
involve the nerve-roots. Under the latter circumstances the 
monoplegia is almost always double. If the functional power of 
the brachial plexus be abolished, the muscles will rapidly waste 
and die. I have seen a condition of the brachial plexus allied to 



74 DIAGNOSTIC NEUROLOGY. 

cerebral and spinal concussion, caused by an ocean wave striking 
from above downward on the supra-clavicular region and fol- 
lowed by total loss of nerve-function. Traumatic and idiopathic 
diseases of the sciatic nerve may cause a crural monoplegia. 

Toxic Monopleg-ias. — Various metals are capable of producing 
monoplegias^ but, practically, lead is the only one which fre- 
quently causes such palsy. Plumbic monoplegia is usually bra- 
chial, and resembles most closely that form of organic monoplegia 
which is due to pressure upon the nerves. It is to be separated 
from this, usually at a glance, by being double ; but I have seen 
one case of single brachial monoplegia due to lead, and one case 
of pressure-monoplegia in which both arms were affected on ac- 
count of the patient's work requiring him to labor with out- 
stretched arms resting near the body upon a narrow board. In 
the plumbic single monoplegia the paralysis was caused by the 
local absorption of the metallic salt, in whose solution the hand 
and arm were habitually immersed. Under such circumstances, 
the diagnosis must be made out by careful attention to the history. 
In plumbic monoplegia the extensors are almost solely affected; 
but this may also be true of the paralysis produced by pressure, 
since the musculo-spiral nerve may be alone implicated, and it 
chiefly supplies the extensors of the hand. It is affirmed that in 
plumbic paralysis the short extensor of the thumb escapes, and 
that this is pathognomonic. 

MULTIPLE PALSY. 

A multiple palsy is one in which two or more groups of dis- 
sociated muscles are involved. The symptoms vary according to 
the seat and nature of the lesion, and are, in a word, the associated 
symptoms of the various local palsies of which the multiple palsy 
is composed. 

A multiple palsy may be of cerebral or of peripheral origin. 
The nature of any individual case is to be determined in the 
same way as in monoplegia, and the reader is referred to page 
69 for the distinction. There is, however, one form of per- 
ipheral multiple palsy in which, although the muscle wastes, the 
reactions of degeneration do not appear. (See Progressive Mus- 
cular Atrophy.) 



PARALYSIS. 75 

Cerebral Multiple Palsies, 

The cells in the cerebral cortex which are connected with motion 
are, as has already been explained, so placed that those which 
lie near one another affect associated or closely-related muscles. 
Cerebral multiple palsies are therefore rare, because a small lesion 
of the cerebral cortex affecting contiguous cells produces a mono- 
plegia, whilst a lesion suflBciently large to affect the whole motor 
zone of one hemisphere produces a hemiplegia. A multiple cere- 
bral paralysis can be produced only by two lesions, or by a lesion 
of such character that it affects scattered areas of the cortex. A 
clot or an embolus affects almost invariably a definite area of the 
cortex, either large or small, and produces, therefore, a hemiplegia 
or a monoplegia. Consequently acute cerebral multiple palsies 
are among the most infrequent of diseases. 

Syphilitic Multiple Palsies. — Syphilis is especially apt to 
produce two or more lesions in the brain : consequently a pro- 
gressive cerebral multiple palsy is in the adult usually syphilitic, 
due to the action of two or more slowly-developing patches of 
gummatous meningitis. 

Multiple Cerebral Sclerosis. — Occasionally the disease known 
as multiple cerebral sclerosis affects the cortical region, or its 
minute scattered patches may even invade the interior portion of 
the brain in such a way as to produce multiple palsies. The 
diagnosis of this disease is especially to be made upon the exist- 
ence of tremors, which occur in the affected parts only during 
voluntary movement. The symptoms and course of the affection 
will be discussed in detail under the head of Tremors. 

Spastic Infantile Paralysis. — One of the most frequent of 
the progressive or chronic multiple paralyses of cerebral origin is 
the affection which is known as spastic paralysis of childhood. 
This is a disease or condition which, beginning in early child- 
hood, continues through life. The palsy may take the form of a 
hemiplegia, paraplegia, monoplegia, or multiple palsy, and in 
some cases the paralyzed region is so small that the patient might 
be considered to be suffering from a local paralysis. The name of 
spastic infantile palsy which has been given to this disease ex- 
presses well its characteristic features, — namely, the presence of 
contractures and the age of attack. 



76 DIAGNOSTIC NEUROLOGY. 



The contractures are so severe as to give rise to very pronounced 
distortions. In the hand the fingers are partially flexed and ir- 
regularly drawn apart, whilst the palm is usually somewhat cup- 
shaped, and the wrist and even the elbow may be in a perpetual 
flexion. In the feet almost any variety of pes equinus may occur, 
but most commonly the toes are drawn downward and inward, 
and the sole is somewhat inverted ; not rarely the feet are crossed. 

Not only may the muscles of the extremities be attacked, but 
also those of the trunk ; and more frequently the neck is affected, 
so that the head is held in various bizarre positions. The mus- 
cles of the face are rarely paralyzed, but permanent grimaces and 
even various squints may show that the muscles of the head have 
not escaped. The rigidity is usually not so complete but that by 
means of moderate force an imperfect return of the limb to its 
normal position may be temporarily produced. 

Spontaneous movements in the limbs are rare, but there may be 
a single or double athetosis and even true choreic movements. It 
is especially in this disease that the so-called ^^ associated move- 
ments^' first described by Westphal occur. When this condition is 
present, movements made in the non-paralyzed extremity are sim- 
ilarly but imperfectly executed in the paralyzed part. Thus, in a 
right-sided hemiplegia, when the fingers of the left hand are 
opened or shut those of the right hand follow the impulse. As 
stated by Westphal, these associated movements do occur in the 
clot-hemiplegia of adults, although they are very rare. 

In spastic infantile paralysis partial loss of power is frequent, 
the muscles responding slowly and imperfectly to the will, but 
without choreic jactations. In other cases the afiected muscles, 
although unable to respond properly to the will, are thrown by 
its efforts into more or less irregular and varied choreiform con- 
tractions. 

The muscles themselves are wasted, firm in substance, with dis- 
tinctly tense tendons, but never offer any electrical reactions of 
degeneration, and, indeed, preserve fully their relations with the 
electric current. The reflexes are never lessened ; usually they 
are somewhat exaggerated, and in some cases they are very 
markedly increased, so that the condition known as spinal epilepsy ^ 
in which violent general contractions are produced by slight ex- 
ternal irritation, may exist. The presence of these grossly exag- 



« 



PARALYSIS. 77 

gerated reflexes or of spinal epilepsy in any individual case seems, 
however, to show that the spastic palsy is not of the pure type, but 
that there are associated with it, either as a result or as an accom- 
paniment, sclerotic changes in the spinal cord especially affecting 
the lateral columns. As already stated, no distinct trophic changes 
occur in the muscles, neither are true trophic changes to be found 
in the other tissues, but there is very frequently a partial arrest of 
development of the affected limb, so that not only is it less in 
diameter but also in length, and the bones and joints are unduly 
small. 

There is no disturbance of sensation. 

Epilepsy is common, and often severe. In the earlier stages of 
the disease the convulsions usually begin in the affected limbs, and 
they may for a time even be completely monoplegic or unilateral, 
but sooner or later they become universal. Not rarely the attacks 
of major epilepsy are associated from time to time with pronounced 
petit mal. 

In most cases there is a lack of mental power. A partial or 
complete aphasia is frequent, and every grade of imbecility, from 
idiocy to the nearly normal condition, may be found. Often also 
there is marked asymmetry of the skull; or the head may be 
excessively large, or perhaps more frequently abnormally small. 

Almost invariably spastic infantile palsy dates back to very 
eai'ly childhood, although occasional cases are developed as late 
as the tenth or twelfth year. I have seen a number of cases 
in which the symptoms were noticed a very short time after a 
birth which had been instrumental, and I believe that not infre- 
quently the disease is due to a meningeal hemorrhage caused by 
the injury to the child^s head by the forceps of the accoucheur. 
In another set of cases the attack dates to convulsions occurring 
during early childhood. These cases afford a twofold history. In 
some of them there is no apparent cause for the convulsions. The 
child is seized with unconsciousness accompanied with violent 
convulsive movements, and is left paralyzed. Under these cir- 
cumstances the convulsions have been invariably more severe in 
the subsequently paralyzed limb. I believe that the pathology 
of these cases is that an apoplexy has occurred with a clot, and 
this clot has been the cause of the convulsive seizure and of the 
after-palsy. In the second set of cases the convulsions result from 



78 DIAGNOSTIC NEUROLOGY. 

an obvious cause, such as gastric irritation or the coming on of a 
scarlet fever or other exantheraatous disease. If under these cir- 
cumstances the child emerges with a permanently paralyzed limb, 
the convulsion has probably produced a rupture of the blood- 
vessel in the brain and consequent hemorrhage. It would appear, 
however, that it is possible for a convulsion occurring in a child 
to be accompanied with so much cerebral congestion of a local 
character as to produce a slight temporary loss of power in the 
limb without the presence of a clot in the brain ; and when this 
congestion is frequently repeated, a progressive structural change 
of the affected portion of the brain is set up. At least such is the 
explanation of cases like those described by Jules Simon (Revue 
mens, des Maladies de VEafance, December, 1883), in which the 
child passes through a series of more or less distinct convulsions, 
each followed by evidences of local weakness and a little stiffness, 
disappearing after a few hours, but continually growing more 
pronounced and more permanent after the successive fits, until 
finally a true contracture is produced. 

Lesion of Spastic Paralysis, — Infantile spastic paralysis is the 
result of sclerotic and atrophic changes in the brain. Such changes 
in most cases date back to the occurrence of the hemorrhage, but 
in other instances, and especially in the slowly-developed cases last 
spoken of, they are the result of frequently-repeated irritative con- 
gestions of the brain-substance. The seat of these lesions varies 
indefinitely, as does the position of the resultant palsies and the 
degradation of the mental condition of the child. 

The only disease with which spastic infantile paralysis could be 
confounded is lateral spinal sclerosis and multiple sclerosis of the 
brain or cord, which certainly may exist in children as in adults. 
In spinal lateral sclerosis there are no convulsions and no arrest 
of mental development, whilst the reflexes are grossly exaggerated. 
In multiple spinal sclerosis the symptoms resemble those of lateral 
sclerosis, but are less severe, and usually pains or other evidences 
of sensory disorder mark the presence of sclerotic patches in the 
sensory region of the cord. In multiple cerebro-spinal sclerosis 
the peculiar tremors are present. It must, however, be remem- 
bered that, especially in childhood, cortical brain sclerosis is very 
prone to give rise to, or to be associated with, secondary conditions 
of the spinal cord, and that not rarely cases occur in which the 



PARALYSIS. 79 

symptoms of these three so-called diseases are mingled because 
the sclerotic changes are so widely scattered through the nervous 
system. 

Peripheral Multiple Palsies, 

Peripheral multiple palsies may be acute or chronic. An acute 
or subacute organic peripheral multiple paralysis is due either to 
a lesion of the nerves or to an affection of the ganglionic cells of 
the anterior cornua of the gray matter of the cord, called polio- 
myelitis. The diagnosis as to which of these parts is affected may 
be difficult. The history of the case is of great importance. In 
the absence of traumatism the paralysis is almost invariably 
due either to poliomyelitis or to multiple neuritis. The diagnosis 
of multiple neuritis has been fully discussed under the head of 
Ascending Palsy. The reader is, however, reminded that the im- 
portant points are the presence of pain and tenderness over the 
nerve-trunks in neuritis, and their absence in poliomyelitis ; also 
that in poliomyelitis the trophic changes occur much more rapidly 
and completely than in neuritis. 

Diphtheritic Paralysis. — A very important form of peripheral 
multiple paralysis is that which follows diphtheria. The symp- 
toms usually commence in two or three weeks after the inception 
of the disease, but may come on as early as the sixth day, or may 
be delayed for four weeks or even longer. In the majority of cases 
the original attack of diphtheria has been mild, and in the lower 
classes I have on several occasions seen the primary disease 
entirely overlooked. In its typical form the palsy begins first in 
the palatine muscles, and is usually revealed by a peculiar twang 
of the voice, resembling that commonly spoken of as nasal. At 
this time, or shortly afterwards, there is a difficulty in swallowing, 
which may become so severe that all liquids are returned by the 
nose, and even the power of swallowing solids is almost lost. 
If the palate be at this time examined, it will be noticed to be 
flabby, motionless, and more or less anaesthetic. The laryngeal 
muscles may now be attacked and difficulty of respiration be 
experienced from paralysis of the abductors of the vocal cords. 
When the laryngeal symptoms are severe, the nasal voice is 
replaced by a whisper, or by a total extinction of sound. The 
tongue, the lips, and even the muscles of mastication may be af- 



80 DIAGNOSTIC NEUROLOGY. 

fected, so that the patient is unable to chew food or to retain 
the saliva, which constantly dribbles from the mouth. The eye- 
muscles are usually the first affected after those of the throat. 
Paralysis of accommodation comes on early, and is soon accom- 
panied by loss of power of some of the muscles of the eyeball, 
giving rise to strabismus and diplopia. Complete mydriasis, with 
ptosis, may also occur from loss of power in the oculo-motor nerve. 
About this time weakness of the legs is noticed and rapidly 
deepens into a more or less complete paraplegia. The arms also, 
and even the muscles of the trunk, may be affected, so that in some 
cases a general palsy results. Even the muscles of organic life may 
be implicated, as is shown by obstinate constipation from paraly- 
sis of the intestinal walls, paralytic retention of urine, and cardiac 
failure. The circulation in severe cases is feeble, and the surface 
cold and blue. In the majority of cases diphtheritic paralysis is re- 
covered from; but death may result — from choking, produced by 
the slipping of a piece of food into the larynx ; from inanition, the 
effect of the loss of power of taking food ; from asphyxia, due to 
paralysis of the respiratory muscles; or from cardiac failure, which 
may develop with great suddenness. In some cases paralysis of the 
diaphragm is revealed by the epigastrium and hypochondrium being 
drawn inward instead of being curved outward during inspiration. 
This condition is one of grave danger. When it occurs, or when 
the pulse is exceedingly weak, or the first sound of the heart is 
markedly diminished, absolute quiet is of the utmost importance, 
as any exertion may produce sudden death from paralytic asphyxia 
or syncope. Sensory disturbances always accompany diphtheritic 
palsy. They consist of anaesthesia rather than of pain, though 
numbness and tingling, with formications, are occasionally felt. The 
distribution of the anaesthesia varies greatly. It may be almost 
universal, or may be confined to the throat, and in some cases 
it affects other mucous membranes, so that defecation and mictu- 
rition may be performed without conscious feeling. Only in rare 
cases are the nerves of special sense affected. 

Polioniyelitis. — The diagnosis of a fully-developed poliomye- 
litis is rarely obscure, but in very acute cases the nature of the 
attack is in its beginning often overlooked. Not infrequently the 
symptoms develop with comparative slowness, weakness of the 
part affected being the first evidence of disease. On the other 



PARALYSIS. 81 

hand^ in some cases there is during the earlier days of the attack 
great systemic disturbance, with high fever and an array of symp- 
toms sufficiently resembling those of malarial or typhoid fever to 
be readily mistaken for them. An examination of the legs and 
arms under these circumstances will detect the presence of some 
localized or wide-spread loss of power, and thereby reveal the 
nature of the disease. Unless the practitioner habitually ex- 
amines the muscles of the extremities and trunk in cases of ob- 
scure fever occurring in children, he will be very apt to make a 
mistake in the early diagnosis of acute poliomyelitis. The gen- 
eral course and symptoms of acute poliomyelitis will be discussed 
in the chapter on Trophic Changes. At present I shall only fur- 
ther point out certain affections which may be confounded with 
the disease. 

Local Atrophies. — Care is sometimes necessary not to con- 
found with a poliomyelitis certain atrophies of the muscles which 
follow injuries or are associated with surgical inflammations. 
Very common among these are palsy of the deltoid, the result of 
a fall upon the shoulders. Paralysis and atrophy of other mus- 
cles from a direct blow may happen, but on account of its situation 
the deltoid is much more frequently affected. After the muscle 
has more or less completely recovered from the immediate effect 
of the bruise, it is found to be completely palsied. I believe 
that in such a case the loss of power is due to concussion, or even 
more severe injury, of the peripheral nerve-endings in the muscle. 
After fractures and luxations, palsies of the neighboring muscles, 
with atrophy, are prone to occur. In some cases they are the re- 
sult of a direct injury to the nerve, or of pressure upon the nerve 
by callus, etc. In other cases no such immediate lesion can be 
made out. Even when a nerve-trunk has been injured it may 
often be noted that the paralysis and atrophy are not confined to 
the muscles innervated by the nerve, and they may become so 
general and wide-spread as to involve all the muscles of the ex- 
tremity. More rarely the muscles upon the opposite side of the 
body are affected with the same changes. To the atrophies in the 
neighborhood of the lesion the name of Atrophy by Propagation 
has been given, whilst the changes at a distance are sometimes 
spoken of as Reflex Atrophies. The lesion in these cases is 
probably an ascending neuritis. 

6 



82 DIAGNOSTIC NEUROLOGY. 

Joint Atrophies. — John Hunter was the first to call attention 
to the muscular atrophies which follow disease of the joints, and 
in 1845 Bonnet discussed the question at length, and showed that 
chronic synovial inflammations may produce wasting not only 
in the immediate neighborhood of the affected articulation, but 
also throughout the limb, and that the aifected muscles are much 
paler than normal and lose a portion of their fibres. Most fre- 
quently in cases of arthritis the extensors are the first to be 
profoundly aifected. This atrophy is not simply loss of muscle- 
tone from want of use. It is always accompanied by paralysis, 
and sometimes the paralysis comes first. It may continue long 
after the arthritis has been cured. It is usually, but not always, 
in proportion to the inflammation in the joint, and is more fre- 
quent with blennorrhagic and scrofulous inflammations than with 
rheumatic arthritis. M. Gosselin has called attention to the pecu- 
liar atrophy with contracture of the long peroneal muscle, which is 
not rarely seen in medio-tarsal arthritis. The loss of opposition to 
antagonistic muscles sometimes in these cases produces great dis- 
tortion in the foot and hand. 

Toxaemic Peripheral Palsies. — An affection which is liable 
to be confounded with idiopathic poliomyelitis, and in which the 
lesion is probably degeneration of the ganglionic spinal cells, is 
produced by poisonous doses of lead or of arsenic, and probably 
of other metals. The loss of power sometimes affects almost the 
whole muscular system, but may be irregularly located either in 
the upper or in the lower extremities. According to my experi- 
ence, almost complete paraplegia, with comparatively trifling arm- 
paralysis, is most frequent after arsenical poisoning, whilst in lead- 
poisoning the upper extremities, and especially the deltoid muscles, 
are prone to be attacked. It must be remembered, however, that 
in either of the poisonings any associated or scattered groups of 
muscles may be affected. The symptoms develop rapidly, the 
affected muscles wasting and presenting in a very short time the 
electrical reactions of degeneration, and finally, in extreme cases, 
passing into a condition in which they fail entirely to react to 
electric currents. The symptoms are similar to those of ordinary 
cases of acute poliomyelitis. The toxic nature of the affection is 
indicated by the disease occurring in adults, in whom acute polio- 
myelitis is excessively rare, by the rapidity of the changes, by the 



PARALYSIS. 83 

wide distribution of the paralysis, and sometimes by the loss of 
power over the bladder and rectum. The diagnosis is further to be 
made out by the history of the case, or, if this be wanting, by the 
occurrence of disorders of sensation as well as of motion. Wide- 
spread or narrowly-limited spots of anaesthesia can usually be 
discovered, at least in the early stages of the disorder. Not 
infrequently the anaesthesia finally disappears, although the motor 
paralysis remains. Especially in arsenical poisoning, and in the 
early stages of the attack, violent pains shoot through the limbs, 
following more or less distinctly nerve-trunks, and giving rise 
to the suspicion that the pathology of some of these cases is a 
peripheral neuritis. It is especially important that a correct diag- 
nosis be made of these cases, because they are nearly always cura- 
ble by treatment. The occurrence of an acute poliomyelitis in the 
adult should always create in the mind of the practitioner a strong 
suspicion of a toxic origin, and the urine should be examined 
for lead and arsenic. Finding the metal of course decides the 
diagnosis, although very frequently the paralysis outlasts the 
apparent elimination of the poison, and no metal can be detected 
in the urine. In lead-poisoning, the occurrence of the blue line 
upon the gums is decisive; but its absence is not proof of the 
absence of lead from the system. 

Chronic Peripheral Palsy. — The most frequent form of 
chronic peripheral paralysis occurring in adults is that which is 
known as progressive muscular atrophy. In this disease, without 
an obvious cause, wasting, with loss of power, appears in the af- 
fected muscle, and progresses so slowly that years may be required 
for the destruction of the part. Under these circumstances the loss 
of power is in direct proportion to the wasting of the muscle, but 
normal electrical reactions of the wasted muscles persist until almost 
the last fibre is destroyed. The explanation of this characteristic 
symptom will be given in the chapter on Trophic Changes, where, 
also, the course of the disease will be spoken of in detail. The 
lesion is a progressive degeneration of the ganglionic motor cells of 
the spinal cord, and hence the term chronic poliomyelitis which 
is sometimes employed as the name of the disease. Progressive 
muscular atrophy is to be recognized by the slowness of its course, 
the peculiarly irregular groupings of the palsies, the fibrillary 
contractions and wasting of the muscles, with conservation of 



84 DIAGNOSTIC NEUROLOGY. 

their normal electrical reactions, and the absence of pain and of 
paralysis of the bowels or of the bladder. 

Pseudo-Hypertrophic Paralysis. — A disease which causes 
multiple palsies, and therefore requires mention here, although 
probably not an affection of the nervous system, is pseudo-hyper- 
trophic paralysis. During infancy or early childhood it is noticed 
that the child is very easily fatigued, walks unsteadily, falls fre- 
quently, and continually supports himself by clinging to chairs 
or other furniture. He soon begins to go up-stairs with difficulty, 
drags himself along by the balusters, and finally cannot ascend ex- 
cept on his hands and knees. He is also affected when walking on 
the level ground : the feet are held widely apart ; the gait becomes 
straddling. In stepping, the active foot is raised from the ground 
by an elevation of the pelvis, and the trunk is bent towards the 
passive leg. Lordosis is apparent, both in standing and in walk- 
ing. The abdomen is thrust forward and the shoulders backward, 
so that a vertical line dropj)ed from between the shoulders passes 
behind the sacrum. In the advanced stages the child is unable 
to rise from the floor or the chair in the ordinary manner. He 
drags himself up with his hands ; or, if he be lying down, and 
no support be forthcoming, he gets upon his hands and knees, and 
then, grasping each thigh alternately, is able to raise himself suf- 
ficiently from the floor to get first one and then the other foot 
upon its sole. He then lays hold of his thighs with successive 
grasps, one above the other, and thus, as it were, climbs up them 
to a standing position. This method of getting on the feet is 
pathognomonic of pseudo-hypertrophic paralysis. A test which, 
in the young child, is almost diagnostic, even at a time when the 
changes of the muscles are not visible to the eye, is the inability 
of the standing child to raise himself upon his toes. 

Sooner or later in pseudo-hypertrophic paralysis the affected mus- 
cles become larger and firmer, with abnormally rounded outlines. 
Occasionally some of them undergo atrophy. The order of de- 
velopment of the paralysis is usually first in the calves, then in 
the gluteal muscles, then in the muscles of the back, then in those 
of the thigh, and finally in those of the arms. This progression is 
not, however, invariable. The electro-contractility of the muscles 
may for a time be normal : later it is diminished to the faradic 
current, abnormal or increased to the galvanic current : finally. 



PARALYSIS. 85 

it is lost to both currents. These alterations are, however, de- 
veloped very slowly. In the advanced stages the knee-jerk is 
abolished. There is no paralysis of the bladder or of the rectum^ 
and no disorder of sensation. Characteristic changes will be seen 
in fragments of muscles withdrawn by cutting trocars. 

LOCAL PARALYSIS. 

Local paralyses may be either centric or peripheral. In the 
large majority of cases they are peripheral. The diagnosis of the 
nature of a local palsy is to be made in exactly the same manner 
as with monoplegias and multiple palsies, and it does not seem 
necessary to repeat what has been already said. 

In order to facilitate the recognition of the muscles and nerves 
which are affected in any individual case of paralysis, I propose 
to consider succinctly the paralyses w^hich result from a loss of 
power in the various nerves and their tributary muscles. 

Oculo-motor Paralysis. — Dilatation of the pupil, ptosis or 
dropping of the upper lid, paralysis of accommodation, squint 
with consequent double vision, are symptoms of loss of power of 
the oculo-motor nerve, w^hose superficial origin is from the inner 
border of the crus cerebri, the deep origin being in the locus niger 
of the peduncles and the gray nucleus in the floor of the aqueduct 
of Sylvius slightly below the tuberculse quadragemini. Partial 
paralysis of this nerve is frequent. In such cases the symptoms 
vary according to the portion of the nerve affected. The functions 
of the eye-muscles are as follows : to turn the eye — superior oblique, 
downward and outward ; inferior oblique, upward and outward ; 
superior rectus, upward and inward ; inferior rectus, downward 
and inward ; internal rectus, directly inward ; external rectus, di- 
rectly outward. xAll these muscles are supplied by the oculo- 
motor nerve except the superior oblique and the external rectus. 
When one of these muscles is paralyzed a squint results. In order 
to determine which muscle is affected, it is only necessary, at least 
in cases of fresh paralysis, to note the position of the head. The 
rule is, the head is so deflected that the chin is carried in a direc- 
tion corresponding to the action of the paralyzed muscle. Megalop- 
sia, or macropsia, is a condition of vision in which objects look 
larger than normal. It is said to indicate paralysis of the external 



86 DIAGNOSTIC NEUROLOGY. 

rectus. Micropsia, in which objects look smaller than normal, is 
said to indicate paresis of the internal rectus muscle. These two 
symptoms are very rare. I have never seen either of them. 

Oculo-motor palsy is in the majority of instances peripheral, 
due to pressure upon the nerve by basal exudations. The com- 
mon cause in adults is a syphilitic meningitis, in children tubercu- 
lar or rachitic meningitis; but it may be produced by a cancerous 
or benign tumor. For other details upon oculo-motor palsy as a 
symptom see page 41. 

Fourth or Trochlear Nerve. — Loss of power of the superior 
oblique muscle of the eye is diagnosed by the fixedness of the eye 
when the head is moved, or, in other words, by the moving of the 
eye with the head. Double vision occurs whenever the subject 
attempts to look straight downward, or at objects situated towards 
the paralyzed side; but the second image disappears when the 
head is turned to look towards the sound side. The distortion of 
vision is especially manifested when any attempt is made to pick 
an object, as money, off a table. The nerve involved is the 
fourth, trochlear, or pathetic, whose apparent or superficial origin 
is in the superior peduncle of the cerebellum. Its fibres have 
been traced into the peduncle to the valve of Vieussens, near the 
tuberculse quadragemini, where they decussate with corresponding 
filaments of the opposite side. 

The fourth or trochlear nerve and the sixth or abducens, like 
the oculo-motor, are frequently paralyzed by basal meningitis, but 
loss of power in them may be due to centric lesion, such as a clot, 
a tumor, or a degeneration of the nucleus. 

Fifth or Trigeminus Nerve. — Loss of power in the muscles 
of mastication, i.e., the temporal, masseter, and pterygoids, and 
in the mylo-hyoid, digastric, tensor palati, and tensor tympani, 
indicates paralysis of the motor root of the fifth or trigeminus 
nerve. This root has its apparent origin in the side of the pons ; 
its deep origin is in a nucleus just below the lateral angle of the 
fourth ventricle, immediately in front of the nucleus of the facial 
nerve. 

Sixth or Abducens Nerve. — Paralysis of the abducens nerve 
causes loss of power in the external rectus, with consequent in- 
ternal strabismus, or squint, double vision, and sometimes ma- 
cropsia. Internal squint does not, however, always indicate 



PABALYSIS. 87 

paralysis of the sixth nerve, because the weakness of the external 
rectus muscle is a very frequent result of imperfection of vision. 
The apparent origin of the abducens nerve is from a groove be- 
tween the anterior pyramid of the medulla and the posterior border 
of the pons. There are usually two roots, one from the medulla 
and the other from the pons. The fibres have been traced to a 
nucleus which lies underneath the fasciculus t^res in the floor of the 
fourth ventricle. A few fibres are believed to pass from this 
nucleus upward and across to join the third nerve of the opposite 
side. In this way are explained certain rare cases of conjugate 
paralysis involving the internal rectus of one side and the ex- 
ternal rectus of the other side, and accompanied by atrophy of 
the nucleus of the abducens nerve. 

Facial Nerve. — Of all the nerves of the body the facial or 
seventh nerve is most frequently paralyzed. The superficial origin 
of this nerve is in a groove between the olivary and restiform 
bodies of the medulla. Its deep origin is probably in the upper 
portion of the pons, although its fibres have not been distinctly 
traced farther than a nucleus in the upper half of the floor of the 
fourth ventricle near the postero-median fissure. It supplies all 
the muscles of the face, except those of mastication, also the levator 
palati and the tensor tympani. 

Centric paralysis of the facial nerve is common. It is never 
complete, and almost invariably affects the muscles about the 
corner of the mouth. It is revealed by the slight drawing of 
the mouth to the opposite side, by loss of power of whistling or 
of fine articulation, and by a little flabbiness of the affected part. 
In deep coma this palsy can often be recognized by the peculiar 
puffing out of the corner of the mouth during expiration. 

Peripheral palsy of the facial nerve is very frequent, constituting 
the affection sometimes known as BeWs palsy. The paralysis is 
always complete, or nearly so. The face is strongly drawn to- 
wards the opposite side. The power of completely closing the 
eye is lost, because the orbicular muscle is not able to raise the 
lower lid. The wrinkles in the forehead and the various folds of 
the skin, to which the face owes so much of its expression, entirely 
disappear or are greatly flattened out. The saliva is with diffi- 
culty retained. Articulation is distinctly impaired. During the 
process of chewing, the food is very apt to accumulate between 



88 DIAGNOSTIC NEUROLOGY. 

the teeth and the cheek, on account of the flaccidity of the buc- 
cinator muscle. Mastication is not otherwise interfered with, be- 
cause the muscles of mastication are not supplied by the facial 
nerve. Bilateral facial para\ysm, facial diplegia, or simultaneous 
palsy of both facial nerves, is exceedingly rare, though it is some- 
times produced by a long transverse lesion crossing the anterior 
half of the pons, or by a similar transverse lesion encroaching upon 
the facial nerves after their emergence. It is characterized by 
a fixed, immovable, expressionless countenance, a peculiar drop- 
ping of the angles of the mouth and collapsed appearance of the 
nostrils during inspiration, and a marked flapping in and out of 
the cheeks during respiration. The voice is usually nasal, and the 
articulation very bad owing to an impossibility of pronouncing 
labial consonants. There is excessive difficulty in retaining the 
food between the teeth, and the saliva in the mouth. 

There are three distinct positions at which lesions of the facial 
nerve-trunk may occur and produce characteristic symptoms. The 
first and most frequent is that in which the point of paralysis is 
at or immediately after the escape of the nerve from the temporal 
bone. Under these circumstances the paralysis is limited to the 
muscles of expression. 

The second form of facial palsy is that in which the lesion is 
situated above the origin of the chorda tympani nerve, but on 
the distal side of the petrosal nerve. Under these circumstances 
to the paralysis of expression is added great diminution of the 
sense of taste in the anterior two-thirds of the tongue. 

In the third variety, the lesion is behind the ganglionic en- 
largement which gives origin to the third petrosal nerve. There 
is now loss of power in the muscles of expression, loss of taste, 
paralysis of the soft palate, as revealed by a depression of the arch 
of the palate upon the affected side, and a loss of power in the 
tensor palati muscle, so that the soft palate is drawn towards 
the normal side. At the same time the sense of hearing is gen- 
erally abnormally acute, and the secretions of the parotid and 
submaxillary gland are deficient. 

Paralysis of the facial nerve may be due to tumors at the base 
of the brain, to disease of the petrous portion of the temporal bone, 
or to simple rheumatic neuritis. Owing to the exposed position 
of the nerve and the habitual nakedness of the face, this paralysis 



PARALYSIS. 89 

is frequently produced by exposure to cold draughts or winds, 
especially after heating of the body. Paralysis from exposure 
usually involves only that portion of the nerve which is external 
to the bony canal, though sometimes the inflammation may extend 
backward into the canal. Complete peripheral palsy of the whole 
nerve is in the great majority of cases due to disease of the bone, 
or to tubercular or syphilitic basal meningitis. 

Glosso -Pharyngeal Nerve. — Paralysis of the glosso-pharyn- 
geal nerve is revealed by difficulty of swallowing, with great ten- 
dency to regurgitation of food through the nostrils, and the loss 
of taste in the posterior third of the tongue. The superficial 
origin of the nerve is in the groove between the lateral tract and 
the restiform body of the medulla oblongata. Its fibres have been 
traced to a nucleus in the floor of the fourth ventricle. 

Spinal Accessory Nerve. — The spinal accessory nerve is com- 
posed of fibres springing from the lateral columns of the medulla 
oblongata and of fibres which rise between the anterior and pos- 
terior roots of the first and fifth cervical nerves, the two parts 
being united in the cranium and escaping as one nerve through 
the jugular foramen. The spinal accessory nerve sends commu- 
nicating fibres to the pneumogastric, which appear to reach the 
laryngeal muscles, since in paralysis of the spinal accessory the 
voice becomes hoarse and unnatural ; the act of deglutition is also 
somewhat affected. It affords the chief but not the only supply 
of the sterno-mastoid and trapezius muscles. 

Sterno-mastoid Muscle. — Paralysis of the sterno-mastoid mus- 
cles causes slight elevation of the chin, with rotation towards the 
paralyzed side, causing an oblique position of the head. There is 
difficulty in depressing the head towards the paralyzed muscle, 
whose normal outline in the neck is also softened down. If both 
muscles be affected, the head is held straight, and is rotated with 
great difficulty ; great difficulty is also experienced in depressing 
the chin. 

Trapezius Muscle. — Paralysis of the trapezius muscle is shown 
by sinking of the point of the shoulder, drooping downward of the 
scapula, the inferior angle being in the relation of adduction to the 
spine as compared with its fellow, and prominence of the clavicle 
and supraclavicular space. If there is also difficulty in raising the 
scapula and clavicle, and in elevating the arm, the upper fibres 



90 DIAGNOSTIC NEUROLOGY. 

of the muscle are especially involved ; while if the scapula is not 
easily approximated to the spinal column, the middle and lower 
fibres are chiefly affected. If after complete paralysis of the trape- 
zius there is absolute inability to draw the scapula towards the 
spine, palsy of the rhomboideus major and rhomboideus minor 
muscles may be inferred. Under similar circumstances loss of 
the power of elevating the scapula, and of moving the neck after 
fixation of the scapula, indicates paralysis of the levator angulce 
scapulce. 

Long' Thoracic Nerve. — If the scapula is drawn upward 
with its lower angle approximated to the spine, and if during the 
act of elevating the arm the lower angle of the bone does not 
describe an arc outward, as it normally should do, but approaches 
still nearer to the spine, w^hile the vertebral border stands out in 
a wing-like manner, leaving a well-marked depression between it 
and the thorax, then there is paralysis of the serratus magnibSy 
which is supplied by the posterior thoracic or long thoracic or 
external respiratory nerve of Bell. 

Subscapular Nerves. — Difficult adduction of the arm, with 
loss of the normal power of depressing it and drawing it back- 
ward, especially in the act of placing the hand in contact with the 
buttock, shows paralysis of the latissimus dorsi muscle, which is 
chiefly supplied by the subscapular nerves. 

Inability to perform properly inward rotation of the humerus, 
diminished power of pronation, excessive outward rotation of the 
upper arm, and consequent faulty position of the hand, denote 
paralysis of the subscapularis and teres major muscles, which 
receive their nerve-supply from the subscapular nerves. 

Supra-scapular and Circunifl.ex Nerves. — Impaired power 
of outward rotation of the humerus, and consequent difficulty in 
performing such acts as writing, drawing, and especially sewing, 
in which this movement is essential, together with excessive in- 
ward rotation, even to the point of turning the ulnar border of 
the hand uppermost, indicate paralysis of the important external 
rotator of the humerus, the infraspinatus muscle, as well as of 
its assistant, the teres minor muscle. The former is supplied by 
the supra-scapular nerve, and the latter by the circumflex. 

When the arm cannot be directly elevated, — i.e., brought at 
right angles with the trunk, — but hangs helpless close to the 



PARALYSIS. 91 

thorax, and, later, when a definite space appears between the head 
of the humerus and the acromion, there is paralysis of the deltoid 
muscle, which is supplied by the circumflex nerve. 

Anterior Thoracic Nerves. — Inability to adduct actively the 
arm so as to draw it across the chest, or to place the hand on the 
opposite shoulder, abnormal prominence of the ribs and inter- 
costal spaces, and loss of tension of the anterior border of the 
axillary space, are the symptoms which show paralysis of the 
pedoralis major and pedoralis minor muscles, supplied by the 
anterior thoracic nerves. 

Musculo-Cutaneous Nerves. — Absence of the greater part of 
the power to flex the forearm, with loss of some of the power of 
supination, and partial lack of ability to draw the humerus for- 
ward, inward, and towards the scapula, point to paralysis of the 
group of muscles supplied by the musculo-cutaneous nerve, — viz., 
the biceps cubitis, the coraco-brachialis, and part of the brachialis 
anticus. 

Musculo-Spiral Nerve. — If the hand hangs at right angles 
to the forearm (wrist-drop) and the power of extension at the 
wrist-joint and elbow-joint is absent, with the hand in pronation, 
the fingers bent, and the thumb flexed and adducted, the deformity 
is characteristic of the group of muscles supplied by the musculo- 
spiral nerve and its posterior interosseous branch, — viz., the triceps 
and anconeus, the supinator longus, the extensor carpi radialis 
longior and brevior, and all the extensor muscles of the superficial 
and deep posterior brachial regions. Other prominent symptoms 
are that the effort at extension of the fingers is possible only in 
the second and end phalanges, while the first phalanges are more 
flexed (the interossei flexing the first phalanges and extending the 
others). The hand-grip is weakened unless the wrist-joint be put 
into extension, and when the hand and forearm are put prone 
upon the table there is diminished power of abduction and adduc- 
tion. The forearm cannot be brought midway between prona- 
tion and supination, and when it is in this position the ability to 
perform elbow-joint flexion is impaired. Finally, the forearm 
cannot be extended upon the arm. 

Median Nerve. — Loss of the power to flex all the second 
phalanges and the end phalanges of the index and middle fingers ; 
preservation of this motion in the first phalanges (interossei), and 



92 DIAGNOSTIC NEUROLOGY. 

its partial preservation in the two outer fingers ; inability to flex 
the thumb or bring it in apposition with the little finger; dimin- 
ished power in flexing the wrist^ which, when this is attempted, 
throws the hand into a marked adduction ; and impaired pronation 
with lessened sensibility of the first two fingers and radial side of 
the ring finger, indicate paralysis of the median nerve. This nerve 
supplies all theflexoi' and pronator muscles of the deep and super- 
ficial anterior brachial region, with the exception of the flexor 
carpi uh^aris and the ulnar half of \hQ flexor profundus digitorum, 
which are supplied by the ulnar nerve, and also all the muscles of 
the thumb except tlie adductor and one head of the flexor brevis 
poinds, and finally the two outer lumbricales. 

Ulnar Nerve. — Imperfect flexion of the hand, which is towards 
the radial side; impaired power of adduction of the hand; less- 
ened ability to separate the fingers (abduction) or to bring them 
together (adduction) ; absence of the power to flex the first row of 
the phalanges and extend the last two rows; almost entire immo- 
bility of the little finger; difficulty in attempting to oppose the 
thumb to the metacarpal bone of the index finger, with disturbed 
sensation of the entire little finger and ulnar side of the ring 
finger, constitute the symptoms of paralysis of the muscles sup- 
plied by the ulnar nerve. These muscles are the flexor carpi 
ulnaris, part of the flexor profundus digitorum^ the interossei, and 
the two inner lumbricales, all muscles of the little finger, and the 
adductor of the thumb and one head of the ^^^or brevis pollicis. 

When the interossei and lumbricales are no longer able to flex 
the first row of the phalanges and extend the other two rows, but 
the extensor communis digitorum excessively extends the first 
row of the phalanges, while the flexor muscles bend the second and 
third row, the condition of ^^ claw-hand^^ is produced, which may 
mean paralysis of the ulnar nerve just above the wrist, so that 
the innervation of the interossei and lumbricales alone is affected. 

Spinal Nerves. — If the head hang forward and cannot be ex- 
tended, or at least can be extended only by the aid of a swinging 
motion, there is paralysis of the extensors of the cervical vertebrae, 
— i.6., the rectus capitis posticus major and minor, the upper portion 
of the trapezius, and the splenii. 

When the spine tends to assume a posterior curvature, most 
marked in the dorsal region, and the patient presents the ap- 



PARALYSIS. 93 

pearance of ^^old man^s back/^ in which he cannot voluntarily 
straighten the curvature, although this may be done by passive 
action, there is paralysis of the extensor muscles of the back, chiefly 
the longissimus dorsi and sacro-lurabalis, and the condition of 
paralytic cyphosis. The production of lateral curvature, or para- 
lytic scoliosis, means that the paralysis is limited to one side only. 

When a patient carries the body with the upper portion bent 
backward, so as to throw it behind the centre of gravity, and 
when the body, if inclined too far anteriorly, falls forward and 
cannot again assume the erect posture until the hands, being 
placed upon the legs, help the arms by a sort of climbing process 
to bring the body again to its backward posture, the condition of 
paralysis of the extensor muscles of the lumbar region obtains, — 
Le,, the erector spince and its divisions. In this condition the 
patient further stands with the head bent forward, walks with a 
swaying motion of the trunk, and when he sits down the upper 
part of the body apparently sinks, so that the dorsal spine is bent 
(cyphosis), while there is a deep concavity of the lumbar spine 
(lordosis). The nerves concerned in these palsies of the back are 
the posterior branches of the spinal nerves, cervical, dorsal, or 
lumbar, according to the region involved. 

Ilio-Hypog-astric — Ilio-Ing'uinal — Intercostal Nerves. — In- 
ability to compress properly the contents of the abdominal cavity, 
so that such acts as urination, defecation, and vomiting are per- 
formed with difiSculty, and diminished powder in the effort of res- 
piration, together with a tendency to fall backward when the upper 
part of the trunk is inclined posteriorly, show paralysis of the 
abdominal muscles, which are supplied by the ilio-inguinal, ilio- 
hypogastric, and lower intercostal nerves. 

Anterior Crural Nerve. — Loss of the power to flex the thigh 
upon the abdomen and extend the leg at the knee, and impaired 
ability to raise the body from the recumbent posture, and to perform 
the acts of walking, running, going up-stairs, and the like, are the 
symptoms which indicate paralysis of the group of muscles sup- 
plied by the anterior crural nerve, — viz., the iliacus, pectineus, and 
all the muscles on the anterior surface of the thigh except the tensor 
vaginae femoris. 

Obturator Nerve. — When the act of pressing the knees firmly 
together, or of crossing one leg over the other, cannot be properly • 



94 DIAGNOSTIC NEUROLOGY. 

performed^ and when there is impaired power of external rotation 
of the thigh while in the sitting posture, the indications are that 
there is paralysis of the gracilis and adductor muscles of the in- 
ternal femoral region and of the external obturator muscle, which 
group is supplied by the obturator nerve. 

Superior and Inferior Gluteal Nerves. — Uncertainty in the 
act of walking or standing, together with absent power of internal 
rotation of the thigh and impaired power of external rotation; 
difficulty in abducting the thigh, with disturbed relation of the 
thigh to the pelvis, and inclination of the latter to the opposite 
side during attempted action on the part of the affected limb, are 
the symptoms which point to paralysis of the muscles supplied by 
the superior and inferior gluteal nerves. The inferior gluteal 
nerve is distributed to the gluteus maximum, which muscle can 
forcibly extend the thigh on the pelvis and perform outward rota- 
tion of the thigh. The superior gluteal nerve passes to the tensor 
vaginae femoris and to the gluteus medius and minimus. The an- 
terior fibres of these latter muscles rotate the thigh inward, while 
their posterior fibres rotate it outward. This group (gluteal), 
when taking their fixed point from the pelvis, are abductors of 
the thigh ; when they take their fixed point from the femur, 
they support the pelvis on the femur. The tension of the fascia 
lata, which may be slackened in palsy, is usually maintained by 
the gluteus maximus and the tensor vaginae femoris. 

Sciatic Nerve. — Inability to flex or bend the knee, to oppose 
resistance to passive extension of the knee, and to raise the heel 
towards the buttock, would show loss of power in the semimembra- 
nosus, semitendinosus, and biceps femoris n^uscles, a group supplied 
by the great sciatic nerve. This is a possible form of paralysis ; 
but more usual are the palsies which occur from affections of the 
principal branches of its distribution, and consist in loss of the 
extension and flexion of the foot and toes and abduction and 
adduction of the foot. 

External Popliteal Nerve. — If the foot cannot be flexed or 
abducted, nor completely adducted, and hangs downward, so that 
the patient in the act of walking raises the foot by flexing the 
hip-joint and then places it again upon the floor in such a manner 
that the point of the toes and the outer border of the foot touch 
the ground first, the symptoms are characteristic of paralysis of 



PARALYSIS. 95 

the muscles supplied by the external popliteal or peroneal nerve. 
This nerve, through its two branches, the anterior tibial and 
musculo-cutaneous, supplies the muscles of the anterior portion 
of the leg and the extensor brevis digitorum on the dorsum of the 
foot. 

Internal Popliteal and Post-Tibial Nerves. — If the foot can- 
not be extended, nor the toes be flexed or moved laterally, and if the 
patient cannot stand upon his toes or properly adduct the foot and 
raise its inner border, paralysis of the group of muscles supplied by 
the internal popliteal nerve and its continuation, the posterior tibial 
nerve, may be inferred. This group consists of the muscles of the 
calf and of the deeper posterior leg-region, and, through the ex- 
ternal and internal plantar nerves, of those of the sole of the foot. 
In this palsy the great toe can neither be flexed nor moved from 
side to side. The foot may assume an appearance similar to the 
" claw-hand^^ described under palsy of the ulnar nerve, and for the 
same reasons. 

Note. — I desire to acknowledge the assistance derived from Dr. K. Heller's 
Path, und Therap. der Krankh. der peripher. Nerven (Wien, 1879) in the 
preparation of the account of Local Palsies. 



CHAPTEE 11. 

MOTOR EXCITEMENTS. 

Disturbances of motility which are accompanied by an 
excess of motion may be well divided for clinical study into 
Convulsions, Spasms, Choreic Movements, Tremors, and Auto- 
matic Movements, to which I shall add, for convenience of de- 
scription, Contractures, although the latter condition of the muscle 
might be very properly considered as essentially diverse from the 
other motor disturbances. 

Convulsions. — A convulsion is a condition in which, owing to 
an excessive discharge of motor impulses from the nerve-centres, 
there is disturbance of the nervous system and usually a wide- 
spread excessive muscular contraction, — either a succession of vio- 
lent momentary contractions and relaxations or a maintained 
contraction. When there is an alternation of contraction and 
relaxation, the convulsion or spasm is said to be clonic. When the 
contraction is maintained for a time, the convulsion or spasm is 
to7iic. Convulsions are further characterized by being temporary 
states. They are naturally divided into general and partial. 

In order to bring a case into the category of general convul- 
sions it is not necessary that the whole of the muscular system 
should be involved, but only a sufficient proportion of it to make 
a wide-spread general disturbance. A partial convulsion is one 
which involves but a limited portion of the muscular system. 

Spasms. — A spasm is a muscular contraction involving only a 
narrow territory, and not connected with a general involvement of 
the nerve-centres. The division between convulsion and spasm is 
to some extent arbitrary. In many cases the nature of the spasm 
is at once apparent. In the so-called Jacksonian epilepsy the 
convulsive disorder may for a time seem to be a local spasm, 
but its more serious nature is sooner or later shown by its con- 
nection with loss of consciousness. A spasm is a local phenome- 
non ; and in any case, so long as there is no disturbance of other 
nerve-functions, a localized muscular contraction must be looked 
96 



MOTOR EXCITEMENTS. 97 

upon as a spasm. It must^ however^ not be forgotten that an ap- 
parently simple local spasm may be the outcome of an hysteria, 
and be therefore the momentary expression of a general neurosis. 

Choreic Movement. — A choreic movement is one in which 
irregular and more or less violent contractions occur^ either in 
single muscles or in muscles which are associated in groups, so 
that a certain amount of resemblance exists between the diseased 
movement and the voluntary motion. 

Tremor. — A tremor is a to-and-fro vibratile movement which 
is produced by more or less rhythmical successive contractions of 
antagonistic muscles. It does not in any way simulate voluntary 
movements. 

Automatic Movements. — The term automatic movements is 
used to signify those motions which occur independently of the 
will of the person, but in which some voluntary act is closely 
simulated. An automatic act often involves an elaborate series of 
movements, such as occur in bowing, getting out of a chair, and 
the like. Cases of this kind belong in the class of chorea major 
of some German writers, but, as there is no relation between these 
motions and true choreic movements, I have preferred the term 
automatic movements. 

CONVULSIONS. 

Convulsions are divided into epileptiform , hysteroidal, and 
tetanic. In the epileptiform and hysteroidal convulsions there is 
a disturbance of consciousness. In the tetanic convulsion the 
nervous discharge comes solely from the spinal cord, and con- 
sciousness is undisturbed. In the epileptiform convulsion the 
disturbance of consciousness amounts to a complete suspension of 
it; whilst in the hysteroidal convulsion there is a peculiar condi- 
tion in which consciousness is seemingly lost, although after re- 
covery the patient remembers all that has happened during the 
convulsion, or in which the patient during the convulsion appears 
to be conscious, but after recovery has no remembrance of occur- 
rences during the fit. 

Epileptiform Convulsion. — In the typical, fully-developed epi- 
leptiform convulsion, the first symptom is a peculiar sensation first 
felt in some part of the body, and rising from its seat of origin up 
to the head, to be lost in unconsciousness. This so-called aura is 

7 



98 DIAGNOSTIC NEUROLOGY. 

succeeded at once by the peculiar scream known as the epileptic 
cry, — a wild, harsh cry, probably due to a forcing of air, by convul- 
sive contractions of the thoracic and abdominal muscles, through 
the glottis, narrowed by a rigid spasm of the vocal cords. With 
the first unconsciousness a general tonic spasm comes on, pro- 
ducing rigidity of the whole body, and violent distortions of the 
head, limbs, and face. The muscles of the trunk and abdomen 
are rigidly contracted. Often a turning of the head and eyes to 
one side is the first evidence of this condition, and in some cases 
not only the head but the whole body rotates. The facial mus- 
cles are violently contracted, usually most markedly on the side 
towards which the head turns ; the jaws are fixed, and often drawn 
to one side; the arms are almost always flexed at the elbow, and 
still more strongly at the wrists, whilst the fingers are flexed at 
the metacarpo-phalangeal joints and extended at the others, the 
thumb being adducted into the palm or pressed against the first 
finger. The position of the fingers is similar to that of grasping 
a pen, and is due to conjoint spasmodic contractions of the interos- 
seous and flexor muscles, as in the so-called athetosis. The legs are 
extended and the feet inverted. The position of the arms, legs, 
hands, and feet is usually that which is assumed in a case of uni- 
versal tonic spasm, the members being drawn always in the direc- 
tion of the muscles of superior power ; but in some epileptic con- 
vulsions this is departed from, showing that certain of the muscles 
are more affected than others. Thus, the fists may be clinched, or 
the legs may be violently flexed and drawn up on the abdomen. 

The stage of tonic spasm is usually accompanied by marked 
pallor of the face, and lasts from a few seconds to one or even 
two minutes, when it is succeeded by the stage of clonic spasm. 
Usually the coming on of this is marked by vibratory tremors 
passing into vibrations, which continually grow both slower and 
more severe until the intermissions become long and complete, 
and the limbs are alternately relaxed and jerked in move- 
ments as wild and bizarre as they are violent. During the 
period of clonic spasm the face becomes red, congested, even 
bloated, and often livid. The expression changes continually, 
since the spasm involves all the muscles of the face, including 
those of mastication and of the tongue, the soft palate, and the 
larynx. Owing to the violent working of the muscles of masti- 



MOTOR EXCITEMENTS. 99 

catioDj the saliva is forced from the mouth in the form of froth. 
The tongue is continually thrust in and out by the spasm of its 
muscles, and is apt to be caught between the convulsively moving 
jaws and severely bitten. If the tongue happens to be between 
the teeth during the period of tonic spasm in an epileptic convul- 
sion, it is bitten in the first stage of the fit. 

The blood-stain which is so characteristic upon the froth is due 
to hemorrhage from the tongue. The pupils at the beginning of 
the fit are sometimes contracted ; absolutely immovable dilatation 
occurs, however, very early, if indeed it be not present from the 
onset, and is the characteristic condition during the whole fit. 
The return of the pupils to the normal state is often one of the 
earliest evidences that the paroxysm has exhausted itself. In 
some cases after the fit the pupils undergo remarkable oscillations. 
During the height of the attack both the pupillary and the con- 
junctival reflexes are abolished. The sphincters are in the ma- 
jority of epileptic convulsions not relaxed, but it is not rare for the 
urine and faeces to be passed, and Gowers affirms that this is more 
apt to occur in nocturnal fits. The pulse, feeble or unaffected in 
the beginning, during the height of the paroxysm is greatly in- 
creased in frequency and in force. 

The stage of clonic convulsion lasts from three to four minutes, 
when it merges into the condition of quiet coma, and this in turn 
passes into a heavy sleep, which may continue for a few moments 
or for hours. After the waking the patient suffers from headache 
and general muscular soreness. 

The description which has just been given represents the 
epileptiform convulsion as it is seen in what may be considered 
typical epilepsy; but even in the majority of cases of epilepsy 
some of the phenomena are wanting, and almost any of them may 
be absent. The essential or central idea of the epileptiform con- 
vulsion is the occurrence of complete unconsciousness, with ner- 
vous discharge taking the form of a clonic spasm, in which the 
movements have no relation, apparent or real, to those of ordinary 
life. The term epileptiform is used to represent any variety of 
such convulsions, because such convulsions occur most frequently 
in epilepsy; and, in a similar manner, the term hysteroidal con- 
vulsion is used to express a convulsion of the general character 
seen in hysteria. The distinction is, however, a somewhat arbi- 



100 DIAGNOSTIC NEUROLOGY. 

trary one, since every gradation between the two forms exists, and 
an hysteroidal convulsion may occur in true epilepsy and an epi- 
leptiform convulsion in hysteria. 

Hysteroidal Convulsion. — In the hysteroidal convulsion the 
tendency is to a prolonged tonic contraction of the muscles, giving 
rise to the assumption of positions which bear more or less re- 
semblance to those that may be taken in health. In the typical 
hysteroidal convulsion consciousness is impaired, but is not en- 
tirely set aside. Thus, a patient apparently unconscious during 
the fit narrates after recovery all that has occurred during the par- 
oxysm ; or, in other cases, what is known as automatic consciousness 
is present, in which the patient during the paroxysm seems to un- 
derstand all that is said, but nevertheless after the paroxysm has 
no remembrance of what has occurred. The hysteroidal convulsion 
of the most highly developed and most pronounced type is usually 
preceded by some warning, — by a special feeling of malaise, epi- 
gastric sensation, palpitation of the heart, giddiness, constriction in 
the throat (the so-called globus hystericus), or, frequently, by an 
aura which appears to arise from the ovary, which under such 
circumstances is almost alw^ays hyperaesthetic. The patient falls, 
but usually gently and not with the suddenness of true epilepsy^ 
Not rarely there is at this time an initial scream, which may be 
repeated during the paroxysms. The pallor of the face may now 
be marked. A simple tonic spasm develops, lasting two or three 
minutes: in it the limbs are usually rigid, with the toes pointed 
downward, and the arms extended or lying at the side of the 
patient. It is at this time that the respiration becomes arrested 
and there is developed the stage of asphyxia of some writers. 
The face is swollen, with turgid veins, and suffocation seems 
imminent. This condition may pass into the characteristic stage 
of opisthotonos, or may be followed by a furious clonic convul- 
sion, in which bloody foam gathers about the mouth, although 
the movements preserve, to some extent, the appearance of wil- 
fulness, so that the head or the arms are struck violently against 
the floor or dashed against pieces of furniture. Following these 
clonic convulsions, or not rarely replacing them, is the character- 
istic stage of opisthotonos, in which the person lying upon the 
back is bent violently into the arc of a circle, so that the body 
rests upon the head and feet, with the central portion arched from 



MOTOR EXCITEMENTS. 101 

the ground. The muscular contractions may be so severe that 
the head is drawn completely backward and the upper portions 
of the body rest upon the face, which looks towards the floor, 
whilst the lower end of the arc is supported on the toes. This 
condition of opisthotonos may last for some minutes. In some 
cases it is interrupted or replaced by violent, purposive clonic 
spasms, the patient suddenly leaping from the bed, or rising into 
a sitting position, and as quickly falling back again in opisthoto- 
nos. This to-and-fro movement may take place with extraordi- 
nary velocity. In some cases the body is bent violently laterally 
instead of backward. The opisthotonic stage may be interrupted 
by various emotional actions, or it may gradually subside into 
what may be called the emotional stage, when the patient assumes 
some attitude of intense emotion, and not rarely the so-called 
posture of the crucifix. In the latter attitude the subject lies 
upon the back, absolutely quiet, with the legs stretched out side 
by side and the arms firmly extended at right angles to the body, 
in the position of the cross. The widely-opened eyes, with dilated 
pupils, appear to be looking into indefinite distance, whilst a 
beatific smile is settled upon the face : so that by the ignorant 
the convulsant is often believed to be seeing visions of heavenly 
joy. Usually the emotion changes from time to time ; the light 
of religious beatitude upon the countenance deepens into an 
intense voluptuousness, attended, it may be, with gestures and 
words full of venereal desire ; or terror becomes supreme, and is 
manifested with equal intensity; or, in a passion of penitence, 
the convulsant, with sobs, bitter cries, and broken words, begs for 
mercy. Again the scene shifts, and, now singing, now weeping, 
reproaching alternately herself and her care-takers, the woman 
passes on to a slowly-perfected consciousness. 

Hallucinations occur during and after the fit, and are always 
correlated to the emotional state: thus, during the terror, the 
subject sees rats and other disgusting objects, which, according to 
Charcot, are usually upon the side that is anaesthetic between 
the paroxysms. 

The hysteroidal convulsion does not necessarily comprise all the 
stages or phenomena which have been just narrated. Indeed, 
convulsions which approximate the description just given are 
exceedingly rare in the United States, and, according to the state- 



102 DIAGNOSTIC NEUROLOGY. 

ments of English authors, also in Great Britain. The writings 
of the school of Charcot indicate that they are frequent in France. 
The difference appears to be connected with race, hysteria being 
more mild in the cold-blooded Anglo-Saxon. Dr. John Guit6ras 
informs me that at Key West, where the inhabitants are generally 
of pure Latin blood, hysteria conforms with the descriptions of 
the French writers. 

Characteristics of Hysteroidal Convulsion. — The varieties 
of hysteroidal convulsion as they occur in hysteria in the United 
States will be discussed in detail later in the chapter. Suffice it 
for the present to state that, as contrasted with the characteristics 
of the epileptiform convulsion, those of the hysteroidal convul- 
sion are the peculiar disturbances of consciousness ; the presence 
of emotional disorders; and the tendency of the muscular contrac- 
tions to simulate in an exaggerated form natural movements and 
to become tetanic. Persistently clonic spasms pertain especially 
to the epileptiform convulsion, whilst tetanic rigidity is indicative 
of the hysteroidal. 

Tetanic Convulsion. — In tetanic convulsion motor discharge 
arises from the spinal cord alone, the brain not being involved ; 
consequently there are no disturbances of consciousness. The 
convulsions may be clonic or tetanic : they are evidently produced 
by irritation of the peripheral sensory nerves, — touching of the 
skin, draughts of air over the face, loud noises, or other feeble sur- 
face-irritations producing at once violent outbreaks. According 
to the cause of the tetanic convulsion is the amount of the mus- 
cular tissue involved. 



EPILEPTIFOEM CONVULSIONS. 

The epileptiform convulsion may be due to — 

First, Idiopathic epilepsy. 

Second, Peripheral irritations. 

Third. Cardiac failure. 

Fourth. Organic disease of the brain. 

Fifth. The action of certain poisons. 

Sixth, Uraemia. 

Seventh, Hysteria. 



MOTOR EXCITEMENTS. 103 

Idiopathic Epilepsy. 

It is necessary to precede the discussion of the diagnosis be- 
tween the etiological varieties of epileptiform convulsions by a 
study in detail of the convulsions as they occur in idiopathic epi- 
lepsy. 

Epilepsy. — As seen in this country, the aura is wanting in a 
very large proportion of cases of true epilepsy. In the majority 
of cases, when present, it is connected either with one extremity or 
with the stomach, although psychical and special-sense auras do 
occur, and in some cases warnings are given by bilateral tremors 
or starts in the limbs, or by wide-spread indefinable sensations, 
which may perhaps be looked upon as generalized auras. Various 
as the auras are in different individuals, they are remarkably con- 
stant in the one sufferer, each epileptic paroxysm conforming to 
those that have preceded it. 

An aura which commences in an extremity is usually first felt 
in the hand, but it may begin in the foot. From the hand it rises 
up the arm as an indescribable sensation, and is not rarely traced 
by the patient to the neck, where it disappears in the development 
of unconsciousness. The gastric aura is very frequent. It is va- 
riously described as pain, as burning or as a sense of coldness, 
as trembling, but more often as an indefinite distress. Usually 
there is no sensation of rising connected with it, but in some cases 
this occurs. An aura may be first felt in the chest, and ascend to 
the throat, when it gives rise to choking sensations. It may also 
begin in the face, tongue, larynx, pharynx, or indeed in any part 
of the body. 

In psychical aura the emotion is almost always that of alarm or 
excessive terror. In very rare cases a very peculiar idea ushers 
in the epileptic convulsion, constituting a true intellectual aura. 

Special-sense auras are rare, but do occur in connection with 
sight, hearing, smell, and taste. Of these special-sense auras the 
gustatory is the most infrequent, the ocular the most frequent. 
The ocular aura may consist in seeing colors ; in an apparent in- 
crease or lessening in the size of objects; in indescribable visual 
sensations ; in double vision, or in loss of distinctness of sight, 
deepening, it may be, into complete blindness. In a few cases 
there are actual visions, either simple or complex. When once a 



104 DIAGNOSTIC NEUROLOGY. 

certain personality, as that of an old woman, or of a man with 
hammer in hand striking a blow, has ushered in a paroxysm of 
epilepsy, the same form ushers in subsequent attacks. In the 
auditory aura, abnormal sounds are heard, such as hissing, or the 
whizz of rushing steam, or intermittent, pulsating noises, such as 
beating of drums or music, and, in very infrequent cases, even a 
spoken word. The olfactory aura seems always to take the form 
of a bad smell. 

There are cases in which two auras coexist. Usually one of 
these is connected with the special senses. 

Sometimes the warning preceding an epileptic paroxysm takes 
the form of a localized spasm, which may occur simultaneously 
with the sensory aura or without it. Usually, under such circum- 
stances, the patient is suflFering from organic brain-disease. 

A very remarkable fact in connection with auras, especially 
those originating in the extremities, is that in many cases their 
upward passage can be arrested, and the fit aborted, by circularly 
compressing the limb above the aura. When the sensation reaches 
the point of compression it ceases, and the patient escapes. I 
have seen a similar occurrence in an epilepsy which commences 
with a motor contraction involving the three fingers. If this 
local spasm be immediately overcome by violently opening the 
clinched fingers, the further development of the paroxysm will be 
prevented. The arrest of the aura in this manner would seem to 
indicate that the starting-point of the epileptic paroxysm is in 
the periphery, where the aura is first felt; but even in some 
cases in which the epilepsy has been due to coarse lesion of the 
brain it has been found possible to prevent the paroxysm by 
checking the upward passage of the aura. To my mind, however, 
this does not absolutely prove, as seems to be believed by most 
recent authorities, that the fit does not really commence in the 
peripheral nerve-endings. For it is possible that in these rare 
cases of organic epilepsy the paroxysms are due to secondary 
changes which have been produced in the peripheral nerve-fila- 
ments. In the famous experiment of Dr. Brown-S^quard, sec- 
tion of the sciatic nerve in the guinea-pig produced structural 
alterations of the skin of the face and an epilepsy which evidently 
arose from the altered surface, and w^as cured by removing the 
diseased skin. With these experiments and facts it seems not at 



MOTOR EXCITEMENTS. 105 

all impossible that a disease of the brain may produce an alteration 
in the peripheral nerve-filaments of a distant part. 

Convulsive Stages. — A brief tonic spasm may constitute the 
whole of the convulsive seizure. The clonic spasm of true epi- 
lepsy is especially characterized by its being universal, although 
one side of the body is often more strongly convulsed than the 
other. According to the elaborate studies of M. V. Magnon 
{L' jSpilepsie paralytique, 1881), during the clonic stage of the epi- 
leptic convulsion the arterial tension and pulse-rate are greatly in- 
creased, but during the tonic convulsion the pulse-rate falls, and 
the rhythm is altered so that a complete systole and diastole may 
occupy six times the normal period. Afterwards the pulse gradu- 
ally approaches the normal, or passes into a state of exaggerated 
force and frequency. During the clonic convulsion the respira- 
tion is noisy, stertorous, slow, or even irregular ; often the pauses 
between the acts are so long that the patient seems to have stopped 
breathing, and when death occurs in a fit it is by the persistence 
of such arrest of respiration. 

Petit Mai. — Almost any of the stages of the epileptiform con- 
vulsion may be absent in epilepsy. To the lighter paroxysm of 
the disease the name of petit mal has been given. In its more 
ordinary form petit mal consists of a momentary loss of conscious- 
ness, accompanied by pallor of the face, which is not, however, 
invariably present. The sufferer, in the midst of a conversation^ 
suddenly stops, is quiet for a few seconds, and then takes up the 
thread of discourse as though nothing had happened, being in 
fact unconscious that anything has happened. Sometimes the 
period of consciousness is followed by a state of confusion of 
thought, and in other cases some peculiar sensation, or some more 
or less indistinct sensory or psychical aura, gives the patient warn- 
ing of the attack. 

The attacks range in degree of violence from the mildest petit 
mal to the most severe convulsions. Sometimes a slight un- 
consciousness is accompanied by a single loud, piercing scream, 
without further motor disturbance. Sometimes the epileptic 
paroxysm is comprised in a brief loss of consciousness, with 
irregular convulsive movements, or with just enough tonic con- 
tractions to cause the patient to fall. So variable is the epileptic 
attack in its manifestations that many authorities consider the 



106 DIAGNOSTIC NEUROLOGY. 

convulsion as secondary, and the unconsciousness as the essential 
portion of the paroxysm. 

Not only the convulsive symptoms, however, but even the un- 
consciousness itself, may be absent in an epileptic attack. In a case 
which was probably one of epilepsy, and in which, so long as I 
had opportunity for watching the symptoms, there was no change, 
the patient had a distinct aura in the hand, rising up the arm 
in the usual manner, but suffering arrest in the neck, at which 
time, without any loss of consciousness, there were violent con- 
vulsive movements of the muscles below the position to which 
the aura had reached. Allied to this case are those described by 
Dr. S. Weir Mitchell in his work on Nervous Diseases, in which 
the whole paroxysm was sensory. In the most pronounced of Dr. 
MitchelPs cases an aura beginning at the feet passed up to the 
head, when it was lost in the sensation of a loud sound, like that of 
an explosion or of a pistol-shot, followed by a momentary sense of 
deadly fear. Dr. Mitchell states that in men he has never seen 
these paroxysms occur except in the border-land between waking 
and sleeping, but that in hysteric females the attacks may take place 
at any time. In some cases instead of the aura being lost in a loud 
noise it disappears in a flash of light, or in an excessively bad 
smell, or occasionally simply in a sense of a blow or of a shock 
on or in the head, or of a rending or bursting. It may be con- 
sidered uncertain how far these cases ought to be ranked as epi- 
leptic. They seem to me to lie very close to epilepsy, and also 
to hysteria. Whatever hesitation there may be in classifying 
these cases, no doubt exists in regard to several cases that I have 
seen in boys, in which the paroxysms for a length of time con- 
sisted simply of a gastric aura, but finally developed into a com- 
plete epilepsy. Thus, a child eight years of age would cry out 
with a sudden painful sensation in his stomach, become excessively 
pallid, run to his mother and be held for a moment, when the 
whole attack would be over. In some of his spells he had tonic 
contractions of the feet and neck. According to the mother, they 
were not accompanied by loss of consciousness, but were followed 
by heavy sleep. Cases of this character show that we cannot con- 
sider loss of consciousness as essential to a paroxysm of idiopathic 
epilepsy. 

As already stated, the especial character of the epileptic convul- 



MOTOR EXCITEMENTS. 107 

sion is the absence of apparent "purposiveness in its movements: 
even this characteristic may be wanting; thus, in the frequently- 
quoted case reported by Professor Trousseau, a Parisian master- 
builder was habitually seized with attacks in which, although 
entirely unconscious, he would run from scaffold to scaffold, 
springing from plank to plank, but never falling. In a negro, 
long under my care, the epileptic paroxysm would begin with a 
scream ; then the man would be seen running furiously ; when 
seized and held, he would fall in a general convulsion. He him- 
self stated that if he were permitted to have his run out, after 
going a quarter to half a mile, he would wake up without falling. 
Various maniacal outbreaks, or emotional disturbances, accom- 
panied by automatic movements, may also replace an epileptic 
paroxysm. (See Disturbances of Intellection.) 

For the reasons which have been assigned in the last few para- 
graphs, and which might be much more elaborated without adding 
to their force, it may be concluded that the essential character of 
idiopathic epilepsy is a tendency to an abnormal discharge of nerve- 
force at irregular intervals^ and without obvious cause ^ but depend- 
ent upon some persistent^ almost irremediable^ state of the nervous 
system. 

Peripheral Inntaiions. 

A reflex convulsion is one which is due to some peripheral irri- 
tation. It is almost invariably epileptiform in its general symp- 
toms, and may conform exactly to the typical epileptic attack. In 
the majority of cases, however, the convulsion is more prolonged 
and more purely clonic in its manifestations. 

In some cases the supposed reflex convulsion takes upon itself 
the hysteroidal form ; but under these circumstances it is exceed- 
ingly difficult to decide how far the convulsive seizures are really 
reflex, and how far they are due to a hysteroidal condition pro- 
duced by the irritation. This is especially true of the numerous 
cases of the so-called reflex spasms, paralyses, and convulsions in 
children which are connected with irritation of the genital organs. 
In my own experience in young children, hysteria is more fre- 
quent in the male than in the female sex : it is also very gen- 
erally connected with an early-acquired habit of masturbation. 
Even when no such habit exists, reflex disorders seem to be 



108 DIAGNOSTIC NEUROLOGY. 

produced by elongated prepuces, and are relieved by circum- 
cision. I believe that not rarely the disease is of an hysterical 
nature, and is relieved in great part by the moral effect of the 
operation. I have seen also a general hysterical state accom- 
panied by severe epileptiform and hysteroidal convulsions and 
distinct hysterical disorders of consciousness, imitation of animal 
movements, etc., produced in a boy by an injury to the head, 
and cured by removal of the cicatrix. Of course it is very diffi- 
cult to say how far, under these circumstances, there was some 
irritation of the peripheral nerve-ending in the cicatrix; but 
there was no tenderness or other local manifestation, and all the 
symptoms partook of the hysteroidal type. We must conclude 
either that reflex epileptic attacks take on the hysteroidal form, or 
that hysteria may be produced by genital irritations in young 
children, and by the moral or physical effects of injuries. 

There are, on the other hand, convulsions which conform to the 
epileptic type, and which are the result of an organic, peripheral 
irritation. Under these circumstances there is often, but not 
always, an aura arising at the point of irritation. In some cases 
there is tenderness at this point, or pressure upon it may produce 
an aura followed by an epileptic attack. The effect of ovarian 
pressure in some hysterical subjects shows how closely even this 
true reflex epilepsy is related to hysteria. In this so-called reflex 
epilej)sy the irritating lesion may be in the extremities, or in the 
trunk, but in the majority of cases it is in the head. When the 
latter is the case, it is always doubtful how far the convulsive at- 
tacks are reflex, and how far they are produced by direct pressure 
or irritation of the nerve-centres. There is nothing in the reflex 
epileptic attack which points out its true character, except when 
there is a localized aura, or when the fit may be caused at any time 
by pressure upon the diseased periphery. The diagnosis is usually 
to be made out by the history of the case and the discovery of the 
point of irritation. In every ease of apparently causeless repeated 
convulsive attacks, it is the duty of the practitioner to search care- 
fully for any possible point of irritation, and if any depression of 
the skull be found, the operation of trephining should be per- 
formed, unless it can be clearly ascertained that the convulsive 
attacks preceded the injury of the skull. In children, especially 
in boys, it is imperative to examine carefully the genital organs. 



MOTOR EXCITEMENTS. 109 

Convulsions of Childhood. — A variety of reflex convulsions 
are the ordinary convulsions of children due to the irritation 
caused by teething, or by indigestible substances in the gastro- 
intestinal tract. In all cases of convulsive seizures occurring in 
young children in which there is no reason to suspect hemorrhage 
into the brain, epileptic disease, or an acute fever, and in which 
there is no point of irritation in the gums or elsewhere upon the 
surface of the body, an emetic should be at once administered. 
The symptoms of gastric convulsion are not peculiar, but usually 
there is no difficulty in arriving at a probable diagnosis if the 
following points are attended to : 

First The convulsion is not one of a series, and is general, and 
not accompanied by paralysis. 

Second, It occurs in young children. 

Third. There is no history of exposure to the contagion of 
scarlet fever or other similar disease, and no fever, excessive vital 
depression, or other symptom of a developing malignant fever. 

Fourth. A history of over-eating, or of the use of indigestible 
food, such as stale cream-puffs, green fruit, candy, etc., may be 
attainable. 

Relations between the Convulsions of Childhood and Epilepsy. — 
The question of the relations between epilepsy and the convul- 
sions of childhood is one of great importance. As already stated, 
I do not believe that the diagnosis between these two affections 
is to be made out by the symptoms of a single fit. Moreover, 
it seems to me positively established by clinical experience that 
the tendency to convulsions in the child is closely associated with 
the epileptic diathesis, and that in many cases accidental convul- 
sions are the commencement of a life-long epilepsy. In a very 
large proportion of the cases of epilepsy there is a history of re- 
peated convulsions during early childhood, and there must be in- 
herent differences in the nervous constitutions of children living 
under exactly similar conditions, some of whom frequently suffer 
from convulsions, whilst others pass unscathed. Some children 
are evidently born with the convulsive tendency, which in many 
cases is so firmly fixed in the nervous system that it cannot be af- 
fected by any mode of life or treatment : its possessor is doomed 
from birth to a hopeless epilepsy. I believe that there is a second 
class of cases in which the epileptic tendency exists, but in so 



110 DIAGNOSTIC NEUROLOGY. 

slight a degree as to be controllable by hygienic and medicinal 
treatment. Under these circumstances the child may suffer from 
repeated attacks of accidental convulsions and become epi- 
leptic, or by great care the early convulsions may be prevented, 
and the nervous system allowed to harden into the normal 
mould. 

Pleuritic Epilepsies. — Among the class of reflex convulsions 
must at present be placed the affection sometimes known as pleu- 
ritic epilepsy, or, in some of its forms, as pleuritie hemiplegia. 
Cases of this condition were first reported by M. Maurice Ray- 
naud in Paris in 1875, since which time a number of records 
have appeared in medical literature. The attacks have been 
caused by the injection of various substances into the pleural 
cavity for the relief of chronic pleuritic affections. They have 
followed the use of very weak solutions of iodine, chloral, carbolic 
acid, etc., and have not been due to absorption of the medicament. 
After the injection, suddenly the face becomes very pale, the res- 
piration is suspended, and the pulse is very small and scarcely 
felt. Generally the spasms are first confined to the face or arm 
of the side in which the injection has been practised, but soon they 
become general, and are accompanied by profound unconscious- 
ness. At first tonic, they almost always in a very short time 
become clonic. The pupils in the beginning of the attack con- 
tract, but afterw^ards dilate largely. The pallor of the face gives 
way to cyanosis as the respiration re-establishes itself and becomes 
stertorous. The urine and faeces are often involuntarily dis- 
charged, and the patient passes into a condition of epileptic coma, 
which may go off in half an hour, or may continue many hours, 
and in some cases has ended in death. A fatal result is usually 
preceded by a true epileptic status, with repeated clonic convul- 
sions and even opisthotonos. A partial hemiplegia (see Union 
MSd.y 1876) has followed pleuritic injections without the occur- 
rence of convulsions : less rare is it for a partial hemiplegia to be 
present after recovery of the patient from the epileptic paroxysm. 
The side in which the injection is practised is the one commonly 
affected. All the recorded cases of pleuritic hemiplegia have 
finally recovered. In the fatal cases of pleuritic epilepsy no 
lesions of the brain have been found. 



MOTOR EXCITEMENTS. Ill 



Cardiac Failure, 



Cardiac Epilepsy. — There is a class of cases in which epilep- 
tiform convulsions occur connected with marked disturbances of 
the circulation. The most prominent symptoms are attacks of 
unconsciousness, which are spoken of by some observers as apo- 
plectic, and by others as epileptic, and a remarkable slowing of 
the pulse. 

The habitual rate of the pulse has in the reported cases varied 
from twenty a minute up to fifty ; usually it is between twenty- 
five and thirty-five. At the moment of the attack of uncon- 
sciousness the pulse-rate diminishes to ten, twelve, or even five 
per minute ; and in the case reported by Dr. P. Thornton {Trans. 
Clin. Soc, London, vol. viii. p. 95) it was proved by stethoscopic 
examination that in the first stage of the attack the heart ceased 
to beat for many seconds. In other cases the stethoscope has 
shown that the heart is acting feebly, although the pulse has been 
lost at the wrist. The respiration is at first usually quickened, 
and may become labored and stertorous. The face is very pale, 
but afterwards becomes congested and livid. The temperature is 
probably in most of these cases below the normal point, and, at 
least in some instances, falls very decidedly during the attack. It 
is quite common for the patient, directly before the epileptiform 
attack, to complain bitterly of intense coldness ; and any case of 
alleged epilepsy in which the body during the attack is excessively 
cold is probably not idiopathic, but cardiac epilepsy. 

Usually, during the stage of unconsciousness the patient lies 
quiet, but there may be very distinct general convulsions, or, more 
frequently, partial convulsions; and biting of the tongue was noted 
even by the earlier observers. (See W. Stokes, Diseases of the Heart 
and Arteries, p. 316.) In some of the reported cases the parox- 
ysms have been ushered in by a distinct aura. On account of the 
conjoint occurrence of unconsciousness and convulsive movements, 
as well as of their irregular, persistent reappearance, these attacks 
are epileptic rather than apoplectic. In most instances the patient 
finally dies in a paroxysm. 

It has been shown by the autopsies reported by W. Stokes and 
by Dr. A. R. Blondeau {£tudes diniques sur le Pouls lent permanent, 
Paris, 1879), and by other physicians, that cardiac epilepsy is con- 



112 DIAGNOSTIC NEUROLOGY. 

nected with fatty degeneration of the heart. The close relation 
of the paroxysms to syncope is further evinced by the fact that 
in one of Dr. Stokes^s cases the attack could be aborted by the 
patient^s getting upon his hands and knees, with his head downward. 
Further, in a considerable number of the cases valvular murmurs 
have been heard. Charcot states that he has seen slow pulse in 
several old people in whom the heart, after death, was found 
to be normal ; and cases were reported by Dr. Halberton {3Ied.- 
Chir. Trans,, vol. xxiv., 1841) in which the affection followed 
an injury of the neck, apparently as the result of a lesion in the 
medulla oblongata. It is possible that in some cases cardiac 
epilepsy is due to irritative lesions of the medulla. 

Organic Disease of the Brain. 

Almost any form of chronic or organic brain-disease may pro- 
duce epileptic attacks, but clinical experience shows that the 
paroxysms are much more apt to be severe and pronounced when 
the upper brain is affected, and especially when the disease is 
situated in or near the motor region of the brain-cortex. Every 
variety of attack which occurs in idiopathic epilepsy is simulated 
in organic brain-disease. From the simplest vertigo up through 
petit mal to the most typical and violent epileptiform convul- 
sions an unbroken series can be traced. Usually, however, certain 
features in the organic epileptiform attacks indicate the true sig- 
nificance of the convulsion. 

At least in my experience, an aura connected with the special 
senses is in the majority of cases associated with some organic 
disease of the centres connected with such sense. When the or- 
ganic brain-disease affects exclusively the motor region the con- 
vulsive paroxysm is not usually ushered in by a distinct aura, but 
in many cases both the sensory and the motor regions of the brain 
are implicated, and under these circumstances the spasm which 
begins the paroxysm is frequently associated with feelings of 
numbness or other parsesthesia in the affected part. Moreover, 
in some cases an aura occurs at a distant part of the body, and a 
true aura of the special senses, or even a psychical aura, may usher 
in an epileptic attack due to organic brain-disease. 

The characteristic phenomenon of the Jacksonian, or organic, 
epilepsy is a continually-recurring tonic or clonic spasm of a 



MOTOR EXCITEMENTS. 113 

group of muscles. Almost any group of muscles may be affected, 
but the various paroxysms in the same case always begin in the 
same way. In studying an individual case it is necessary to 
observe especially the starting-point, the march, and the range 
of the spasm. There are three points at which it is not rare 
for a spasm to originate. The most frequent is probably the 
hand, then the foot, then the face and tongue. The range or 
spread of the convulsion varies from the slightest spasm con- 
fined to the thumb and index finger, and not accompanied with 
loss of consciousness, up to the violent general epileptiform con- 
vulsion. 

According to their range, attacks are well divided into mono- 
spasms, — i,e,y spasm of the arm, face, or leg, — hemispasms, corre- 
sponding in range to hemiplegia, — and general convulsions. In the 
hemispasms the convulsions may be confined to the face, arm, and 
leg, but often there is in addition a turning of the eyes and head 
to the convulsed side, with more or less contraction of the respi- 
ratory muscles of both sides. This tendency of the respiratory 
muscles of the two sides to undergo consentaneous spasm is evi- 
dently etiologically connected with the fact that in hemiplegia 
they usually escape paralysis. In accord with the theory of 
Broadbent, which was explained in the chapter on Paralysis, one 
brain-hemisphere is evidently able to affect the respiratory mus- 
cles of each side. 

Usually, if a spasm becomes general, after having affected the 
hand, it is by marching up the arm and down the leg, or up the 
leg and down the arm, and then crossing to the other side. 
There are cases in which the spasm begins not in the hand or 
foot, but in the shoulder or thigh, when the march of the spasm 
is down the limb. The relation of the spasms in these cases to 
the seat of the lesion is similar to the relation of paralysis to 
organic disease of the brain. This relation has been fully dis- 
cussed in the chapter on Paralysis, and I shall not occupy more 
space with it : contenting myself with the statement that an irri- 
tative lesion in the motor region of the brain-cortex will produce 
spasms of those muscles which would be paralyzed by a totally de- 
structive lesion of the same brain-centres. A lesion may partially 
destroy the functional power of a centre and thereby cause a par- 
tial local palsy, and at the same time irritate the remaining nerve- 

8 



114 DIAGNOSTIC NEUROLOGY. 

cells and fibres^ so that a Jacksonian epilepsy not rarely coexists 
with partial paralysis. 

In Jacksonian epilepsy consciousness may or may not be lost. 
Usually, although not invariably, the degree in which conscious- 
ness is affected is in direct proportion to the severity and range of 
the convulsions : it will be often noted that, whilst consciousneas 
is preserved in the early portions of the paroxysm, it is finally 
lost. When the portion of the brain affected is situated near the 
speech-centres, a temporary partial aphasia not rarely follows the 
fit. Indeed, as shown in the case reported by Dr. Allen Sturge 
{Trans. Internat. Med, Cong., London, 1881), a sudden complete 
aphasia may form the most marked phenomenon in the organic 
epileptic attack, and may develop with the first convulsive move- 
ments, or, possibly, even precede them. More common still is a 
partial loss of power in the convulsed extremity, continuing for 
some hours after the passage of the paroxysm. When the con- 
vulsive seizure is narrow in its range, the weakness is apt to 
amount to a partial paralysis in the restricted region of the con- 
vulsion. When, however, the epileptiform seizure has been a 
very wide-spread and severe one, a hemiplegic weakness not 
amounting to a palsy is often noticed. 

Severe general epileptiform convulsions often usher in an acute 
inflammation of the brain. Under these circumstances the deli- 
rium, the headache, the intolerance of light and sound, the fever, 
and the tendency to coma indicate the existence of a meningitis. 
Convulsions may also be a part of an attack of sunstroke. They 
are frequently present in tubercular meningitis. Whenever they 
are produced by a generalized disease of the brain they do not 
take on the Jacksonian type, — i.e., they do not affect especially 
any group or associated groups of muscles, but are themselves 
generalized. Their causation is to be made out by paying atten- 
tion to the symptoms associated with them. 

Diagnosis between Idiopathic and Organic Epilepsy. — The diag- 
nosis of an organic epilepsy can be usually made out with a 
fair degree of certainty by a study of the convulsive seizures. 
Before giving a positive opinion, however, it is usually wisest to 
wait for other manifestations of organic braip-disease. In idio- 
pathic epilepsy the convulsive movements very rarely begin 
habitually in one extremity, and whenever convulsions have such 



MOTOR EXCITEMENTS. 115 

origin they are probably due to organic focal brain-disease. This 
probability approaches a certainty if the convulsive movements 
be entirely confined to one limb^ one side of the face, or any other 
narrow muscular territory. 

The age at which the epileptic paroxysm has first appeared is 
a matter of vital importance in the diagnosis between idiopathic 
and organic epilepsy. The statements of Gowers and of Hasse, 
including between them about two thousand five hundred cases of 
supposed idiopathic epilepsy, show that in seventy-five per cent, 
the disease commenced under twenty years of age. In Gowers's 
fifteen hundred cases, only about two per cent, began after the 
fortieth year, and about five per cent, after the thirty-fifth year. 
I believe that these small percentages would suffer still further 
reduction if there could be a rigid exclusion of organic cases; 
and it may be laid down as a rule of sufficient accuracy for 
practical diagnosis that an epilepsy loMch develops after the thirty- 
fifth year of age is not idiopathic, but is due to some organic brain- 
disease, to the abuse of alcohol, reflex irritation, or other causes, 
which in some cases may be so hidden as to be exceedingly difficult 
of recognition. An epilepsy which first appears after the thirtieth 
year should be viewed with great suspicion. In my own experi- 
ence, epilepsy occurring after the age of thirty-five, not dependent 
upon assignable causes unconnected with organic brain -disease, 
has in at least eighty per cent, of the cases been due to syphilitic 
lesions of the brain. 

Convulsions from Cerebral Hemorrhag-e. — An epileptiform 
convulsion may be produced by a cerebral hemorrhage. Under 
these circumstances the convulsive movements very frequently 
take on the form of a Jacksonian epilepsy, and may be confined 
to a group of muscles, to one extremity, or, more commonly, to 
one half of the body. The true nature of such a case can usually 
be made out without difficulty by attention to the evidences of 
local palsy. Thus, the face is drawn to one side, or an inequality 
of the pupils or of the movements of the eye can be made out, or, 
still more frequently, a distinct hemiplegia can be discovered, even 
though the patient be comatose. (See Apoplexy.) The apoplectic 
attack also usually occurs in advanced adult life, and is either 
the first convulsion the patient has had, or has been preceded 
by previous attacks of apoplexy. A cerebral hemorrhage may 



116 DIAGNOSTIC NEUROLOGY. 

happen during an epileptic fit. Under these circumstances the 
diagnosis can scarcely be made out until the recovery of con- 
sciousness, when the persistent paralysis will reveal the lesion. 

Epileptiform Convulsions in General Paralysis. — Epileptic 
convulsions are a very common symptom of the disease known 
as general paralysis of the insane. They usually occur in the 
second or maniacal stage of the disease, and are still more fre- 
quent in the final stages of dementia. Many years ago Esquirol 
called attention to the fact that a succession of epileptic fits very 
frequently closes the scene in general paralysis. Epileptic con- 
vulsions may occur in the beginning of a general palsy, and may, 
indeed, usher in the disease. Under such circumstances their 
significance may readily be overlooked. This is especially the case 
when the major attacks are replaced by or associated with petit mal, 
in which the only symptom of the seizure may be a sudden pallor 
with mental confusion or a momentary unconsciousness, or a 
dilatation of the pupils with drawing of the head, or a sudden 
fixation of the countenance with an outpouring of cold perspira- 
tion, or an automatic repetition of coherent or incoherent phrases. 
Such paroxysms are apt to be interpreted as syncopal. Not rarely 
epilepsy in general paralysis takes upon itself the Jacksonian 
form, the convulsion being limited to isolated groups of muscles, 
or to one side of the face, one leg, or one arm, or being hemi- 
plegic. Usually the attack begins with an aura, which is es- 
pecially apt to be vertiginous. Sometimes the convulsion is pre- 
ceded for several days by excessive restlessness, tinnitus aurium, 
and great psychical excitation. In other cases it begins with 
vomiting. 

Very frequently there is a succession of convulsive attacks, 
producing a true epileptic status. In this condition the successive 
convulsions may be very different from one another, one being 
complete, the next partial, in one the head being drawn to the 
right, in the next to the left, and so on. Frequently after the 
paroxysms convulsive tremblings persist in the single muscles, or 
in groups of muscles, for many hours, and are followed by a more 
or less pronounced partial palsy. To use the words of Dr. 
Nicholl, paralysis follows the convulsion or spasm as the shadow 
follows the body. During the more severe paroxysms conscious- 
ness is always lost, but, especially when the convulsive movements 



MOTOR EXCITEMENTS. 117 

are more or less local, it may be perfectly maintained ; occasionally 
it is affected as in hysteria. After severe seizures the mental 
condition of the patient is almost always distinctly aggravated. 

It is affirmed by many authors that in general paralysis the 
temperature rises during and immediately after the epileptic 
paroxysms, and sometimes also immediately before them, and 
that the elevation continues for some hours, and may be very 
considerable after severe fits. This, however, does not seem to be 
universally the case, since Mendel {Paralysis der Irren^ Berlin, 
1880) affirms that he has repeatedly studied the temperature in 
cases in which there was a prolonged convulsive attack, and in 
which no elevation of temperature occurred. In a single case 
Mendel found that the temperature fell very decidedly as the 
result of an epileptic status which had lasted three hours. He 
also states that Westphal has noticed the same thing. Usually, 
however, a distinct sinking of the temperature in the course of 
an attack of unconsciousness during general paralysis marks the 
development of a true apoplexy. 

Toxcemia. 

Epileptiform convulsions may be produced by a very large 
number of poisons. The nature of such attacks is to be made out 
by a history of the case, and by the presence of other symptoms 
of the poisoning. 

Convulsions in Fever. — Among the toxaemic convulsions 
are. to be placed those which usher in scarlet fever and other 
malignant diseases. The diagnosis in these cases rests upon the 
recognition of the febrile disease. Excessive vital depression, 
with lowered or elevated bodily temperature ; the absence of evi- 
dences of the convulsion being reflex, due to acute or chronic 
brain-disease, or uraemic ; the age of the patient, and the history 
of exposure to the cause of an acute febrile disorder, are the 
principal facts which should lead to a correct diagnosis. 

Alcoholic Epilepsy. — There are two distinct epileptic con- 
ditions produced by intoxicating drinks. In one of these the 
convulsions are symptomatic of acute poisoning, and come on 
during an orgy, or immediately after a single excessive draught 
of liquor. 

In the second form the convulsions are apparently not the im- 



118 DIAGNOSTIC NEUROLOGY. 

mediate result of alcohol in the bloody but are developed at a time 
when the system is not profoundly under the direct influence of 
the poison. These epileptic convulsions may supervene during 
delirium tremens, when they are accompanied by hallucinations; 
during the mental enfeeblement of profound chronic alcoholism, 
when they are associated with dementia, paralysis, or stupor ; or 
at a time when the general symptoms of chronic alcoholism are 
not pronounced. In the alcoholic convulsion the symptoms may 
closely resemble those of true epilepsy, and not rarely the attack 
is ushered in by headache, gastric embarrassment, troubles of 
vision, excessive tremors, or some similar prodrome which may 
be looked upon as partaking of the nature of an aura. The con- 
vulsions usually occur in paroxysms, — two, three, four, or more, 
one after the other, at intervals of a few minutes. 

Not only may major epilepsy be closely simulated by the alco- 
holic affection, but simple epileptic vertigo or true petit mal may 
exist, either alone or associated with the major convulsions. 

Alcoholic epilepsy is often associated with hallucinations, es- 
pecially of terror, and the convulsion is not rarely followed by 
temporary mental derangement, which may last only for a few 
minutes or may continue for hours or days. The mental de- 
rangement may take the form of an acute dementia, in which the 
intellectual functions seem to be in abeyance, and the subject is 
reduced to the condition of an automaton, obeying immediately 
and mechanically all commands and impulses from without. 
This state of perverted consciousness has, in some instances, 
lasted for days. Suicidal impulses are very frequent. 

There is nothing diagnostic in the convulsion of alcoholic epi- 
lepsy, and it is especially important to remember that if under 
the prolonged use of the stimulant the epileptic paroxysms have 
occurred repeatedly, they may continue even if the patient cease to 
use intoxicating liquors. Under these circumstances it must be 
considered that an idiopathic epilepsy has been produced by alco- 
hol. In every case of apparently causeless epilepsy occurring in 
middle life, the possibility of its being alcoholic must be borne in 
mind. 

Urcemia. 

Ursemic Convulsions. — A very frequent cause of epileptic 
convulsions is uraemia. In this disease the convulsive phenom- 



MOTOR EXCITEMENTS. 119 

ena may be altogether wanting during the attacks of coma, or 
may appear only in the shape of twitchings of various groups 
of muscles ; but severe convulsions of the epileptic type are fre- 
quent. In these there are usually complete insensibility, rotatory 
movements of the eyes and head, violent clonic contractions of all 
the muscles, biting of the tongue, foaming at the mouth, and 
finally coma : so that it is not rarely impossible from the con- 
vulsion alone to decide that the attack is not true epilepsy. Even 
when disease of the kidneys has not been previously suspected, a 
history of prolonged dyspepsia, frequent vomiting, occasional at- 
tacks of asthma, failure of general health, etc., may generally be 
obtained, and an examination of the urine will usually reveal the 
nature of the case; but sometimes such examination must be made 
repeatedly before evidences of kidney-disease can be found. The 
danger of overlooking the serious nature of ursemic eclampsia is 
especially great when the convulsive seizure takes on the hys- 
teroidal type. So long ago as 1840, Dr. Bright described cases of 
uraemia in which there were furious convulsions without loss of 
consciousness; and Dr. Roberts has reported similar instances. 
I have seen the diagnosis of hysterical convulsions persisted in 
by practitioners of large experience until within a few hours of 
death. In all cases of convulsions occurring for the first time 
during adult life, a very careful study of the urine is essential. 

Moreover, fatal uraemia may occur with a urine that is appar- 
ently normal, and in a large proportion of cases of contracted 
kidney albumen is absent from the urine for long periods. The 
study of the specific gravity of the urine is of the utmost impor- 
tance, and in doubtful cases the percentage of urea should be 
determined. Unless diabetes insipidus exists, a specific gravity 
habitually below 1010 is almost proof of the existence of chronic 
Bright's disease. In doubtful cases a number of examinations of 
the urine taken at different periods of the day should be made. 
Fasting urine may be found to be of abnormally low specific gravity, 
and urine voided three or four hours after a heavy meal to contain 
albumen. The power of elimination of the iodide of potassium 
has been proposed as the means of testing the renal secreting sur- 
face. It is affirmed that, after a full dose, this drug can, in an 
hour, be readily recognized in the urine by adding nitric acid and 
then starch, but that when contracted kidney exists the iodide 



120 DIAGNOSTIC NEUROLOGY. 

fails to appear^ or comes over in only very small quantities and 
after a very long interval. 

HYSTEROIDAL CONVULSIONS. 

The symptoms of hystero-epilepsy have been sufficiently de- 
tailed in the discussion on the hysteroidal convulsions. It was 
there shown that the attack is usually ushered in by an aura, and 
is made up of peculiar disturbances of consciousness, of emotional 
storms, and of clonic and tonic convulsions, simulating to a greater 
or less degree purposive movements. 

The major hysterical convulsion varies almost indefinitely. The 
ordinary hysterical attack which we see habitually in the United 
States may be well spoken of as minor hysteria. 

Minor Hysteria. — Into minor hysterical paroxysms enter all 
the elements of the major affection ; but usually some of the 
symptoms are wanting in individual attacks, and not rarely a 
single stage constitutes the whole paroxysm. 

The aura is not usually present, unless the so-called globus hys- 
tericus be considered to represent it. The globus is, however, a 
local convulsion, and is not necessarily prodromic. It is described 
as a feeling of a ball in the throat, or of something rising in the 
throat, and is the result of spasm of the muscles in and around 
the larynx. In ordinary minor hysteria the emotional state is 
usually well developed, and is especially prone to express itself 
by uncontrollable laughter or equally uncontrollable sobbing or 
crying. A very characteristic performance which I have seen, 
especially in young boys, is that which may be termed beast- 
mimicry, in which the patient bites or snaps or snarls like a dog, 
or crows like a cock, or in some other way imitates the movements 
and the vocal acts of the lower animals. Among these cases 
belong the not rare attacks of spurious hydrophobia, in which, 
either with or without severe general convulsion, the subject shows 
profound dread of water, great emotional disturbance, often crying 
out to be held lest he bite some person, and continually snarls and 
barks and attempts to bite. These symptoms do not closely re- 
semble those of true hydrophobia, in which disease the subject 
never offers to bite, and does not make any noises resembling those 
of the dog or any other lower animal. Beast- mimicry may be 
Considered as diagnostic of hysteria. 



MOTOR EXCITEMENTS. 121 

The convulsive symptoms of minor hysteria are tonic rather 
than clonic. More or less persistent rigidity is very frequent and 
very characteristic. It may last for hours, or may pass by in a 
few moments. The disturbances of consciousness take the form 
which has already been fully described in speaking of the major 
attacks. Occasionally the abolition may be complete, but almost 
invariably at some stage of the attack the characteristic alterations 
of consciousness can be discovered. The diagnosis between fully- 
formed hysteroidal epilepsy and idiopathic epilepsy is, of course, 
easy, but I have seen in private and dispensary practice patients 
suffering from recurrent irregular attacks whose nature remained 
very doubtful for months. One great difficulty in these cases is 
that the physician is usually unable to see the patient during the 
paroxysm. A further complication arises from the fact that 
severe hysterical manifestations may follow immediately upon an 
epileptic fit, and that hysterical convulsions may alternate with 
those of true epilepsy. The only safety is to be found in a very 
cautious diagnosis and prognosis, especially when the subject is a 
youDg woman. In such patients I have several times seen "spells'^ 
which I had believed to be epileptic yield to careful treatment. 

Temperature as an Aid to Diagnosis. — Aid in the diagnosis 
between ursemic convulsions, hystero-epilepsy, and epilepsy can 
sometimes be obtained by a study of the temperature. In 1865, 
Dr. Kien (Gaz, MSd. de Strasbourg^ 1865, p. 12) called attention 
to the fact that even when the ursemic convulsions are very 
violent they are accompanied by a marked fall of temperature, 
which increases until death. This has been confirmed by Roberts, 
of Manchester, by Hirtz, Hutchinson, Charcot, Teinurier, and 
Bourneville. (See jStudes din, et therm, sur les Maladies du Syst. 
nerveux, Paris, 1873.) In the severe isolated attack of epilepsy 
there is usually a distinct elevation of temperature. In the severe 
isolated hysteroidal convulsion the temperature also rises, but not 
so distinctly as in true epilepsy. In the epileptic state — i,e,, in 
that condition in which there is a prolonged series of fits, con- 
nected by coma and occurring at short intervals — the temperature 
rises steadily throughout the whole condition, this rise of tem- 
perature not being preceded or interrupted by a fall. On the 
other hand, when the series of convulsions are the expression of 
a hystero-epilepsy, the temperature falls very rapidly imme- 



122 DIAGNOSTIC NEUROLOGY. 

diately after each convulsion, and does not in the successive 
attacks reach distinctly higher than in the first convulsion. In a 
supposed hystero-epilepsy a continuous elevation of temperature 
is sufficient to establish the presence of some other disorder, or at 
least of a very threatening condition of the nerve-centres. Thus, 
in a curious case reported by Quincke (Arch, der Heilkunde, 1864), 
after a series of apyretic hysterlform convulsions, convulsions oc- 
curred with an elevation of temperature to 43° C, and soon ended 
in death. Puerperal convulsions are usually supposed to be 
ursemic, but according to the researches of Bourneville they are 
distinctly separated from uraemia by the fact that the temperature 
rises almost brusquely in the beginning of the convulsions, and, 
when the latter are frequently repeated, maintains itself at an 
elevated position with great steadiness. Each paroxysm is marked 
by a slight increase of heat, and if the attack is to end fatally the 
temperature finally becomes very high ; if recovery occur, the 
temperature gradually falls. I am, however, doubtful whether 
the temperature always falls in true uraemia. I have certainly 
seen it rise in coma occurring in persons suffering from contracted 
kidney, and apparently uraemic. The subject is one of much in- 
terest, and needs further clinical study. It is also complicated by 
the frequency of serous or true apoplexy in uraemia. Clinical 
studies of the temperature should, as far as possible, be checked 
by post-mortem results. 

TETANIC CONVULSIONS. 

The tetanic convulsion is one in which the cerebrum does not 
participate, and in which, therefore, consciousness is not disturbed 
except secondarily as the result of asphyxia. i 

It may be due to — -. 

1. Hysteria. 

2. Tetanus. 

3. Poisoning. 

4. Tetany. 

Hysteria. — Hysteria may produce convulsions which conform 
to the tetanic type, but usually, sooner or later, the cerebrum is 
involved, and the characteristics of the hysterical convulsions ap- 
pear. The diagnosis of hysterical tetanus is fully discussed on 
page 126. 



MOTOR EXCITEMENTS. 123 

Tetanus. — Tetanus is characterized by tonic contractions of 
many of the muscles, associated with violent paroxysms of reflex 
convulsions affecting the whole body. There are two distinct 
etiological varieties of it, — the traumatic and the idiopathic. 
The traumatic disease is due to a traumatism, usually a lacera- 
tion, although it may follow a blow, or may occur after child- 
birth. Idiopathic tetanus in many instances comes on without 
obvious cause, but not rarely follows exposure. There are no 
distinctive symptoms separating the two varieties, except it be in 
that the idiopathic disease is less violent and less frequently fatal 
than is the traumatic affection. The diagnosis between the two 
varieties must rest upon the history. 

Tetanus usually begins with mild symptoms, which gradually 
increase, although in rare cases the attack is sudden and the 
course of the disease very short : thus, in a patient of Groetzner, 
the convulsions set in the moment a ligature was tied around the 
crural nerve, and proved fatal in six hours. Jaccoud speaks of a 
case reported by Bardeleben, in which a negro died of tetanus 
fifteen minutes after receiving a wound. On the other hand, tet- 
anus may not appear until long after the reception of the injury, 
and may run a very prolonged course, with active symptoms 
lasting for four or five weeks. 

The first manifestation of the disorder is usually a stiffness of 
the muscles of the lower jaw, of the oesophagus, and, in a little 
while, of the neck. At first the jaw can still be opened, but in a 
short time the masseters set so firmly in tonic spasm that the upper 
and the lower teeth are immovably pressed together. At the 
same time the spasm of the oesophagus increases so that swallow- 
ing becomes very diflScult and fatiguing. The speech is altered in 
distinctness and in tone, not only because the lips and the tongue 
are rigid, but also because the muscles of the larynx are impli- 
catedo The facial muscles of expression are very rapidly in- 
volved; the forehead is wrinkled; the eyebrows are drawn up- 
ward, with the eyeballs staring and motionless and the pupils 
generally contracted ; the corners of the mouth are pulled out- 
ward and downward, and the lips parted so that the teeth are 
exposed, whilst the naso-labial folds are exaggerated. As the 
spasms persist, the face sets itself into an anxious, frightened, 
wildly-excited, half-laughing, half-crying expression, to which 



124 DIAGNOSTIC NEUROLOGY. 

the name risus sardonicus has been given. ^ Spasm of the muscles 
of the neck soon succeeds, if it does not accompany, the first evi- 
dences of the disease, and in a very short time the whole erector 
spinse group are involved. Somewhat later the muscles of the 
legs and of the arms are affected, the tonic spasms being more 
marked in the legs, and in some cases the forearms and the hands 
entirely escaping. Painful spasmodic erections of the penis may 
now occur. 

When the tonic spasms are thoroughly established, the body 
assumes a characteristic position : the head is drawn back ; the 
trunk arched into opisthotonos; the belly hard and spasmodically 
retracted ; the legs rigidly contracted. Paroxysms of violent in- 
crease of the tonic spasms now occur, or brief, furious discharges 
of nerve-force give the appearance of rapidly-repeated clonic con- 
vulsions. During the paroxysm the distorted position of the 
body is greatly increased. With a sudden shuddering the opisthot- 
onos becomes marked, the head is forced back into the pillow, the 
flattened abdomen is thrown forward, and the feet are driven into 
the bed, so that the body rises until it assumes the form of a bow 
resting upon the head and the feet. The spasm of the respiratory 
muscles and of the pharynx and glottis arrests respiration, and 
causes not only a sense of suffocation but an absolute cyanosis, 
which may continue until unconsciousness and even death result. 
Usually during the attack the thorax is spasmodically bound in 
the position of inspiration and the diaphragm is rigidly drawn 
downward. The respiration, arrested during the paroxysm, may 
be rapid between the convulsions ; the pulse is sometimes not af- 
fected, but usually becomes more and more rapid, and the arterial 
pressure, at first high, especially during the convulsion, falls as 
exhaustion sets in. The skin is bathed in sweat, whilst from 
the bronchial mucous membrane there is usually an outpouring 
which, as coughing is impossible, may accumulate in the bron- 
chial tubes and be a very distinct factor in the production of 
suffocation. 

The temperature in some cases of tetanus does not rise distinctly, 
but very frequently it steadily mounts upward ; and in fatal cases 
as death approaches this rise may suddenly become extreme, occa- 
sionally reaching, according to the observations of Wunderlich, 
113^ F. A remarkable but well-authenticated phenomenon is 



MOTOR EXCITEMENTS. 125 

that after death from tetanus the temperature of the body often 
continues to rise for a time. 

The paroxysms of tetanus are reflex, and are provoked by the 
slightest peripheral irritation : a loud sound, a bright light, a 
draught of air, a new contact with the bedclothes, intestinal 
peristaltic movements, an irritation so slight as in health not to 
be noticed, may cause an immediate furious convulsive outbreak. 

The sufferings during an attack of tetanus are extreme. During 
the whole course of the disease there is usually excessive sleep- 
lessness, and the patient is tormented not only by pain, but 
also by distressing thirst, and in some cases by a very acute 
hunger, both the thirst and the hunger being, in a measure, due 
to the difficulty of opening the mouth and of swallowing. The 
cramp-pain is horrible, is more severe during the paroxysms, and 
is in direct proportion to the severity of the contractions. The 
effects of these sources of distress are increased by the character- 
istically clear mental state. In scarcely any other disease is there 
so much anxiety and dread. Retention of urine is frequent, but, 
especially in children, involuntary micturition may occur; rarely 
the urine is passed in large quantities, usually being distinctly 
below the average amount ; it is of high specific gravity, and of a 
dark brown color. Sugar and albumen are exceptionally present. 

Trismus Neonatorum. — A variety of tetanus very rare in this 
country is the so-called trismus neonatorum, which occurs in 
new-born babes. In it the spasms are confined chiefly to the 
muscles of the jaw. Some authorities believe that it is a trau- 
matic tetanus due to irritation of nerve-filaments in the stump of 
the umbilical cord ; others, that it is produced by pressure upon 
the medulla during labor; others, that it is due to phlebitis and 
other pyaemic manifestations. Like other forms or varieties of 
tetanus, it is connected with epidemic influences, and is notably 
worse in extremely hot or extremely cold weather. It is probable 
that the starting-point varies in different cases, and that the epi- 
demic or atmospheric influences act as strong predisposing causes. 

Differential Diagnosis of Tetanoid Affections. — The only dis- 
eases w^hich could possibly be confounded with tetanus are tet- 
any, meningitis, strychnia-poisoning, and hysterical convulsions. 
Cerebro-spinal meningitis is distinguished at once by the cerebral 
symptoms; whilst in a pure spinal meningitis the radiating pain 



126 



DIAGNOSTIC NEUROLOGY. 



along the nerve-cords ought to reveal the nature of the affection. 
The diagnosis between tetanus and tetany is given on page 128. 

About fifteen years ago, in a very important medico-legal case, 
there was pronounced disagreement between the medical experts 
in regard to the nature of certain convulsions. The following 
table, which I published shortly afterwards, was based upon the 
experiences of that trial. Time has confirmed its correctness. I 
have since seen one case in which a broker, after prolonged ex- 
citement on a very hot day, was suddenly seized with nausea, 
directly followed by general convulsions closely conformable to 
those detailed in the second column. These convulsions were un- 
doubtedly hysteroidal, provoked by exhaustion and gastric irrita- 
tion. 

Hysterical Tetanus. 



Tetanus. 



Commenced with blindness and 
weakness. 



Muscular symptoms usually 
commence with pain and stiff- 
ness of the back of the neck, 
sometimes with slight muscu- 
lar twituhings ; come on grad- 
ually. 

Jaw one of the earliest parts 
affected ; rigidly and persist- 
ently set. 



Persistent muscular rigidity, 
very generally with a greater 
or less degree of permanent 
opisthotonos, emprosthotonos, 
pleurosthotonos, or orthot- 
onos. 



Consciousness preserved until 
near death, as in strychnia- 
poisoning. 



Muscular symptoms commenced 
with rigidity of the neck, 
which gradually " crept over 
the body," affecting the ex- 
tremities last. 

Jaws rigidly set before a convul- 
sion, and remained so between 
the paroyxsms. 



Persistent opisthotonos and in- 
tense rigidity between the 
convulsions, and after the 
convulsions had ceased the 
opisthotonos and intense ri- 
gidity lasted for hours. 



Consciousness lost as the second 
convulsion came on, and lost 
with every other convulsion, 
the disturbance of conscious- 
ness and motility being simul- 
taneous. 



Strychnia-Poisoning. 

Begins with exhilaration and 
restlessness, the special senses 
being usually much sharp- 
ened. Dimness of vision may 
in some cases be manifested 
later, after the development 
of other symptoms, but even 
then it is rare. 

Muscular symptoms develop 
very rapidly, commencing in 
the extremities, or the con- 
vulsion, when the dose is 
large, seizes the whole body 
simultaneously. 

Jaw the last part of the body to 
be affected ; its muscles relax 
first, and even when during a 
severe convulsion it is set, it 
drops as soon as the latter 
ceases. 

Muscular relaxation (rarely a 
slight rigidity) between the 
convulsions, the patient being 
exhausted and sweating. If 
recovery occur, the convul- 
sions gradually cease, leaving 
merely muscular soreness, and 
sometimes stiffness like that 
felt after violent exercise. 

Consciousness always preserved 
during convulsions, except 
when the latter become bo 
intense that death is im- 
minent from suffocation, in 
which case sometimes the 
patient becomes insensible 
from asphyxia, which cornea 
on during the latter part of a 
convulsion, and is almost a 
certain precursor of death. 



MOTOR EXCITEMEXTS. 127 

Draughts, loud noises, etc., pro- Desired to be fanned. The " slightest breath of air" 

duce convulsions, as in strych- produces convulsion, 

nia-poisoning. 
May complain bitterly of pain. Crying-spells, in which he Patient may scream with pain, 

" sobbed violently," and or may express great appre- 
" cried like a child," alter- hensions, but " crying-spells" 
nated with convulsions. would appear to be impossi- 

ble. 
Eyes open, rigidly fixed during Eyes closed. Eyes stretched wide open. 

the convulsion. 

The spasm in leg must have Legs stiffly extended, with feet 
been partial, as the feet were everted, as the spasms affect 
crossed and toes inverted, all the muscles of the leg. 
which could not happen if all 
the muscles were involved, 
because the muscles of ever- 
sion, being very much the 
stronger, would of necessity 
overcome the antagonistic 
muscles, and the feet be 
everted. 

Tetany. — Under the name of Intermittent Tetanus, Dance 
originally described the convulsive disorder now usually known 
by the title given to it by Corvisart, — i,e., tetany. It is a disease 
of childhood and early adult life^ and is exceedingly rare in this 
country. If the various writers upon the subject are to be credited, 
tetany may be produced by excessive lactation, by the puerperal 
state, by exposure to cold, by prolonged fatigue, by exhaustion 
from diarrhoea or other cause, by the irritation of intestinal worms, 
by exposure, and even by the rheumatic diathesis or the infectious 
fevers. Further, it is affirmed that it may result from excessive 
emotion, and spread from patient to patient as an epidemic, — facts 
which would indicate an hysterical nature. It consists essentially 
of successive tetanic convulsive attacks, separated by intervals of 
quiet and repose. The paroxysms may continue for some minutes 
or for many hours, and may cease gradually or abruptly. Ar- 
thralgic pains, formications or numbness in the hands, radiating 
pains in the fingers, temporary partial blindness, headache, sense 
of fatigue, etc., are assigned as occasional prodromes. Usually the 
spasms are most marked in the upper extremities, and sometimes 
are confined to them ; the fingers are drawn together so as to form 
a cone like the hand of the accoucheur when he is about to in- 
troduce it into the vagina. Rarely there is a more accentuated 
flexion of the fingers, and still more infrequently the hand and 
the fingers are stiffly extended. 

The feet may be attacked ; sometimes cramps of the calf occur 



128 DIAGNOSTIC NEUROLOGY. 

without distortion, but in other cases the feet are violently ex- 
tended^ with the toes pointing downward^ or very rarely they are 
flexed. The thigh usually escapes, but spasm of the abductors 
and crossing of the feet have been noticed. It is affirmed that 
the spasms may be confined to the arms, but that the legs are 
never the only portion of the body attacked. Only in the severest 
cases are the trunk-muscles affected ; but opisthotonos and men- 
acing dyspnoea do occur. Even more exceptional than these are 
spasmodic closures of the jaw^ and distortions of the face. The 
course of the disease may be painless ; sometimes, however, neu- 
ralgic pains run along the nerves, and usually cramp-pains are 
present in the affected muscle. Anaesthesia and analgesia are or- 
dinary phenomena. According to Erb, the faradic excitability 
of all the muscles of the body is increased. The course of the 
disease is often slow, may continue for months, and usually ends 
in recovery. A diagnostic sign first discovered by Trousseau is 
that during the periods of relaxation, and in some cases even as 
long as three days after the occurrence of a convulsion, the latter 
can be brought on by pressure upon the principal nerve-trunks 
or blood-vessels. By this symptom, by the complete relaxation I 
between the attacks, and by the j)artial character of the convulsion, 
tetany is at once distinguished from tetanus. 

LOCAL SPASMS. 

For the purposes of diagnostic study local spasms are usefully 
divided into those which affect the muscles of organic life and 
those which attack the voluntary muscles. 

Spasms of the Muscles of Organic Life, 

CEsophageal Spasm. — In spasm of the oesophagus the diagno- 
sis of the nature of the stricture can usually be made out without 
trouble ; but, if there be a reasonable doubt, the patient should be 
etherized, when, if the stricture be spasmodic, a probang can be 
passed into the stomach without the resistance which would be met 
with in organic disease. The spasmodic affection develops rapidly, 
and usually without a history of the causes which produce oeso- 
phageal lesion: it is mostly painless, varies excessively from time 
to time, and is apt to disappear suddenly. It is usually accom- 



MOTOR EXCITEMENTS. 129 

panied by distinct hysterical or neurotic symptoms, or occurs in a 
person who has such a history. 

Rectal Spasm. — Rectal stricture is occasionally so closely coun- 
terfeited that the diagnosis can be made out only by physical ex- 
ploration. Under these circumstances the flattening of the stools 
and the other evidences of organic disease are produced by a spasm 
of the sphincter ani. Spasm of the rectum and of its sphincter is 
very prone to be associated with vaginismus and spasmodic dys- 
raenorrhoea. It also is occasionally produced by the pressure 
of a misplaced uterus upon the sacral nerves. 

Urethral Spasm. — Urethral spasm is usually caused by some 
irritant substance in the urine, such as cantharides, but in some 
cases is hysterical in its origin. It is to be recognized by its sud- 
den development, and by the absence of a history of gonorrhoea. 
Etherization will always decide a doubtful case. 

Vomiting'. — A symptom which may be considered as a form of 
local spasm is vomiting. Vomiting of course accompanies many 
acute fevers or disorders, but in its chronic form it is usually either 
due to disease of the stomach, liver, or kidneys, or of the brain, 
or is hysterical. In any case of chronic vomiting it is essential to 
determine at once the condition of the stomach, liver, and kidneys, 

Ursemic vomiting is accompanied by dyspeptic symptoms, is 
very obstinate, and generally is associated with headache, asthma, 
or other ursemic manifestations. Its diagnosis rests chiefly, how- 
ever, upon the detection of the disease of the kidney. 

The cause of chronic gastric vomiting is sometimes difficult of 
determination. It is necessary to examine for the existence of a 
tumor, or of pain and tenderness, or of blood in the matters vom- 
ited. In ulcer of the stomach the pain is habitually referred to 
the back, between the shoulders, or sometimes as low down as the 
lumbar region. In hysterical vomiting there is frequently pain 
in these parts, and not rarely blood will be found in the vomit. 
The practitioner is especially liable to be deceived when along 
with these manifestations there are gastric tenderness, exces- 
sively foul tongue, and pronounced dyspeptic symptoms. The 
hysterical pain in the back is usually, if not always, associated 
with marked superficial tenderness, or hypersesthesia, which is 
wanting in the organic disease. In cases of hysteria the diagnosis 
of gastric ulcer should be made with reluctance. 

9 



130 DIAGNOSTIC NEUROLOGY. 

Tumors, inflammations, and other diseases of the brain may 
produce vomiting. There is nothing in the vomiting which is 
characteristic, unless it be its apparent causelessness, and the fact 
that in many cases it is affected by rapid change of posture : thus, 
vomiting, which is not present so long as a horizontal position is 
quietly maintained, may be at once provoked by the subject's rising 
suddenly from the bed. The diagnosis of nervous vomiting is in 
most cases to be reached chiefly by the process of exclusion, and 
by the discovery of symptoms, other than the vomiting, pointing 
to disease of the brain. 

Nervous Cough. — A form of repeated rhythmical spasm which 
is especially seen in persons suffering from minor hysteria is the 
so-called nervous cough, which may exist independently of ca- 
tarrhal or other organic irritation of the respiratory tract, or may 
be associated with such irritation. 

The cough is usually ringing, dry, and very loud, often rasping, 
and apparently excessively annoying, and is prone to occur in 
violent paroxysms. It must not be forgotten that not rarely the 
catarrhal and nervous elements are associated. Under such cir- 
cumstances the treatment, to be successful, must be directed to each 
element of the condition. The diagnosis of nervous cough is 
arrived at chiefly by exclusion, — i.e., by finding that cough in 
a neurotic subject is entirely disproportionate to the amount of 
catarrhal disease. 

Phantom Tumor. — A phenomenon which may be considered 
the result of a conjoint spasm of muscles of voluntary and invol- 
untary life is the so-called phantom tumor. This occurs almost 
exclusively in neurotic women, and consists of an apparent local 
swelling and hardness in the abdomen, which on palpation gives to 
the hand a sensation like that imparted by a true abdominal tumor. 
Its true character is usually at once revealed by the absence of 
percussion dulness ; but it is said that organic percussion dulness 
may be simulated. Abdominal section has been practised for the 
relief of a phantom tumor due simply to a local spasm of the ab- 
dominal walls, and probably also of the intestines. In all cases of 
alleged or apparent abdominal tumors in hysterical women sus- 
picion should be aroused, and, if there be any doubt, the patient 
should be etherized, when the nature of the alleged growth will be 
revealed by its disappearance or its permanence. 



MOTOB EXCITEMENTS. 131 

Spasms of Voluntary Muscles. 

Laryngismus Stridulus. — A very important form of local 
spasm is the so-called spasm of the glottis^ or laryngismus stridu- 
lus, which is probably the result of contraction of the two thyro- 
arytenoid and the two lateral crico-arytenoid muscles and the 
arytenoideus muscle, and is due to an irritation of the recurrent 
laryngeal nerve. Laryngismus stridulus is a very rare affection 
in adults, and when it occurs in women is usually hysterical. 
In men it is of very serious import, as in most cases it depends 
upon dangerous organic disease. The attacks come on without 
warning, and may occur during either the night or the day. In 
the mildest form the child throws itself backward, grows pale, and 
makes uneasy movements with its extremities. In a few seconds 
the attack is over; the child is left irritable, and is sometimes pun- 
ished for naughtiness. In the more violent paroxysms there is 
whistling or crowing inspiration, preceded by irregular, laborious, 
and audible expiration, or even by a momentary arrest of respi- 
ration. In the severest paroxysms the closure of the glottis is 
complete, so that the thorax, diaphragm, and anterior abdominal 
muscles remain immovable. The child, exceedingly pale, and 
with a wild expression of anxiety in its countenance, throws its 
head back, with the mouth wide open, and the nostrils dilated. 
The face now rapidly becomes cyanotic ; a cold sweat covers the 
forehead, and the blue lips purse out in a manner almost pathog- 
nomonic. If the spasm continue, unconsciousness and convulsive 
symptoms rapidly develop. 

The muscular contractions may take the form of tonic cramp 
of the lower legs with abduction of the big toe, or other distor- 
tions about the feet ; sometimes the arms are similarly contorted. 
Not rarely general tonic and clonic convulsions, with involun- 
tary discharges of urine and faeces, occur. This condition of un- 
consciousness and convulsions may last from a few seconds to two 
minutes, and occasionally ends in death. Usually crying or 
whistling inspirations mark the beginning of the relaxation of the 
spasm ; the irregular inspirations become rapidly normal ; the 
feeble, quick pulse regains its ordinary character, and the general 
cyanosis passes off*. Very frequently after the paroxysm the child 
goes to sleep. If it does not, it is invariably peevish. 



132 DIAGNOSTIC NEUROLOGY. 

( 

Laryngismus stridulus can hardly be confounded with any 
other disease. It is to be distinguished from catarrhal croup by 
the sudden beginning of the attack ; the whistling or crowing in- 
spiration ; the noisy expiration ; the increasing cyanosis; the fre- 
quent loss of consciousness, and general convulsive phenomena; 
the feverless course; the short duration of the paroxysms, and 
their termination through convulsive crowing inspiration ; and 
especially by the absence of cough and other evidences of catar- 
rhal inflammation of the larynx between the paroxysms. In the 
majority of cases the disease is connected with rachitis, and it is 
closely allied to rachitic epilepsy. In some cases the spasms seem 
to be due to reflex irritation from teething; or they may be the 
result of irritation of the nerves by enlarged glands ; and especially 
in adults it is necessary that the larynx be explored for evidences 
of local ulcerations. In extremely rare cases the symptoms are 
said to have been dependent upon local disease of the medulla 
oblongata. 

Occupation Neuroses. — Under the name of occupation neu- 
roses may be associated diseases which are connected with the 
excessive use of localized groups of muscles in business or pro- 
fessional occupation. Because the symptoms are most frequently 
seen as the result of the excessive use of the pen, the disease is 
typified in the so-called writer's cramp; but it also occurs among 
telegraphers, dancers, pianists, workers in metal, etc., when it is 
known as telegrapher's cramp, dancer's palsy, hammer palsy, 
etc. 

The symptoms are undoubtedly produced by the excessive 
repetition of movements requiring exceedingly fine co-ordination, 
and differ from the simple muscular exhaustion which occasion- 
ally is produced by severe, gross muscular efforts. In 1868, 
Moritz Benedict stated that there were three forms of occupa- 
tion neuroses, — the paralytic, the spasmodic, and the tremulous. 
These varieties undoubtedly exist in nature, although not abso- 
lutely separated from one another, — the distinction between them 
being simply that in some cases the paralytic symptoms are most 
marked, whilst in others the spasm or the tremor is the most 
pronounced. According to my own observation, the paralytic 
form of the affection is much the most frequent, although some 
authorities assert that the spasmodic is the ordinary variety. 



MOTOR EXCITEMENTS. 133 

I shall take the writer^s cramp as a type of the occupation neu- 
roses. In the paralytic form of it the first symptom is usually a 
painful feeling of fatigue in the arm, which is often associated 
with formications and numbness, but usually not with true anaes- 
thesia or hyperaesthesia. Only in rare cases can tenderness be 
found over the nerve-trunks. The pain is always increased by 
writing, and at last it grows so intolerable as altogether to forbid 
the use of the pen. With this fatigue and pain there is usually a 
sense of stiffness, and often a distinct muscular resistance when the 
effort is made to grasp the pen. At first no pain is felt when the 
arm is not used, and during use the pain is confined to the arm 
itself; but by and by, if efforts be persisted in, the sense of fatigue 
becomes more or less permanent, and extends upward from the 
arm, and may often be felt as a distinct pain between the shoulders. 
During all this time the power of the muscles for coarse work is 
in most cases not sensibly impaired, but the execution of any form 
of fine work is usually interfered with. 

Even in the paralytic form of writer^s cramp there is a certain 
amount of irregular spasmodic contraction of the muscles during 
the act of writing, as is especially shown by the stiffness and, 
occasionally, by the cramp of the fingers around the pen ; but in 
the spasmodic form of the affection irregular muscular contrac- 
tions are the dominant symptom. At first there are only simple, 
slight spasmodic movements of the thumb and first finger, so as 
to produce an irregular stroke in the writing, but after a time the 
spasms become stronger and more wide-spread. By a sudden ex- 
tension of the finger the pen is dropped, or by a spasmodic action 
of the opponens pollicis with abduction and coincident flexion of 
the index finger the pen is rapidly moved from the paper, or oc- 
casionally a violent spasmodic flexion of all the concerned fingers 
holds the pen as in a vice. In extreme cases all the muscles of 
the forearm are involved; and it is asserted that the muscles of 
the arm and shoulder may be affected, although I have never seen 
an instance of this. 

Much the rarest form of writer's cramp is that in which tremors 
are the most prominent manifestation. When any attempt to 
write is made, tremblings in the hand and forearm, and in extreme 
instances in the arm itself, come on. The pen, following the 
tremors rather than the effort of the will, soon makes nothing but 



134 DIAGNOSTIC NEUROLOGY. 



II 



irregular undulating or angular strokes, in which not even the 
vestige of a letter can be made out. I have never seen a case in 
which tremors existed as the sole symptom, but I have seen them 
very marked in the spasmodic form of telegrapher's cramp, and 
have noted their persistence during almost all forms of voluntary 
movement, even after the occupation had been abandoned for 
months. 

The symptoms of writer's cramp naturally lead to the suppo- 
sition that it is a peripheral affection ; but that it is intimately 
connected with a disordered condition of the nerve-centres is indi- 
cated by the fact that when the victim attempts to substitute the 
left hand for the right the cramp appears in that member also ; 
and also by the circumstance, which I have repeatedly noticed, 
that it may be the first symptom of a general break-down. 

Cortical Spasms. — Any of the muscles of the extremities or 
of the trunk may be affected with a local spasm. Such spasms 
may be due to disease of the cerebral cortex. The nature of such 
attacks is to be recognized by the occasional occurrence of Jack- 
sonian epilepsy, or by the presence of other indications of disease 
of the cerebrum. 

Hysterical Spasms. — Localized spasms are frequently hysteri- 
cal. The nature of such a spasm is to be recognized by its appar- 
ent causelessness, by its sudden onset and departure, and by the 
presence of other hysterical manifestations, and the absence of 
evidence of organic disease of the brain, spinal cord, or nerves. 

Inflammatory Spasms. — Localized spinal meningitis and 
spinal tumors, by irritating nerve-roots, may give rise to tonic and 
clonic spasm of the muscles tributary to such nerve-roots. The 
cause of such contractions is to be recognized by the presence of 
pain and vertebral soreness, either upon direct or indirect pressure, 
or of other symptoms of disease of the spinal membrane or of the 
vertebrae. Again, rheumatic contractions of the muscles may be 
mistaken for true local spasms : the diagnosis under these circum- 
stances is to be made out by observing the presence of excessive 
pain upon passive or active motion, tenderness upon pressure, 
aching pains in the part when at rest, and other evidences of rheu- 
matic disease, either in the present or the past history of the case. 

Reflex Spasms. — Sometimes local spasm is of reflex origin. 
The recognition of these reflex spasms is often a very important 



MOTOR EXCITEMENTS. 135 

aid to the practitioner in diagnosing subacute disease of the joints 
or of the vertebral column. In any case of suspected joint or 
vertebral disease^ a close examination should be made as to the 
power of motion in the part : thus, the patient in whom incipient 
caries of the spinal cord is suspected should be stripped, stood up 
with the feet close together, and then required to bend forward, 
backward, and laterally as far as possible. If it be found that the 
muscles of the back are thrown into spasm by any of these move- 
ments, the existence of local disease of the bone is very probable. 
The presence of the muscular spasm can sometimes be made out 
when otherwise it might be overlooked, by noticing that the move- 
ments in some one direction are very much more restricted than is 
normal. 

Apparently Causeless Spasms. — A localized spasm in the 
trunk or extremities which is not hysterical, and for which no 
definite cause can be assigned, should, if persistent, be viewed with 
great suspicion, as it may be a manifestation of a hidden incipient 
centric disorder. There are, however, cases in which no cause for 
a local spasm can be made out, although the spasm may be abso- 
lutely intractable to treatment. Thus, I have seen a robust man, 
without discoverable disease of the genital or other organs, and 
without history of sexual or other excesses, in whom the testicles 
were frequently drawn up by spasm of the cremaster muscle with 
such force as to cause sickness of the stomach and syncopal sensa- 
tions from the violence of the pain. 

I shall not occupy space with details of the various distortions 
or irregular movements produced by spasms of the extremities. 
The reader who is desirous of tracing a spasm in any individual 
case to the affected nerve and muscle is referred to the pages upon 
local palsies. 

A spasm, of course, causes phenomena which are the reverse of 
those produced by the corresponding palsy : thus, a spasm which 
produces abduction of the hand is due to an irritative lesion of 
the muscle and nerve, whose palsy causes loss of the power of 
abduction. 

There are, however, certain muscular territories belonging to 
cerebral nerves in which spasm is so frequent, so severe, and so 
hidden in its causes as to require special notice. 



136 DIAGNOSTIC NEUROLOGY. 

Facial Nerve Spasm. — First among these cephalic spasmodic 
aflPections is that which affects the distribution of the facial nerve. 
When spasm of the muscles of the face is accompanied by pain, 
it is spoken of as tie douloureux ; when there is no pain, the spasm 
is known simply as tie. 

The contractions of a tic may affect all the muscles of expres- 
sion, or may be limited to a very few of them. In the violent 
type of the disorder there is an incessantly repeated clonic spasm 
of the muscles of one side of the face, causing, in perpetual suc- 
cession and alternation, winking, wrinkling of the forehead, move- 
ments of the nose, and even of the ears, drawing upward and 
downward of the angle of the mouth, etc. Usually the convul- 
sive movements occur in paroxysms, lasting from a few seconds 
to as many minutes, then gradually subsiding into quiet, which 
persists for a greater or less length of time. Sometimes the 
periods of relaxation are very brief, or may seem altogether want- 
ing. The paroxysms vary in number from two or three in the 
twenty-four hours up to thirty or even forty an hour. They are 
usually mild during the night, and sometimes disappear entirely 
when the patient sleeps. 

Grasset asserts that, according to Jaccoud, such cessation is a 
proof of the reflex origin of the spasm ; but I believe that this is 
not correct. Although almost any of the muscles supplied by the 
facial nerves may be affected, the spasms are especially prone to 
attack the orbicularis palpebrarum, the levator labii superioris 
alseque nasi, the zygomatici, and the corrugator supercilii : more 
rarely the frontalis or the platysma, and still less frequently the 
muscles of the ear, are attacked. The stylo-hyoid, the digastric, 
and the velum palati are very rarely, if ever, affected. 

In some cases (in my experience especially when the attack is 
hysterical) the motor disturbance involves the various neighboring 
nerves. If the motor root of the trigeminus sympathize, the 
muscles of mastication are violently convulsed, so that the jaws 
are jammed together ; and if at the same time there exists a uni- 
lateral spasm of the pterygoids, the teeth are violently ground on 
one another. If the hypoglossal nerve is affected, the tongue is 
thrust in and out of the mouth, and may be caught and severely 
bitten. 

In a proportion of the cases of facial spasm certain points can 



MOTOR EXCITEMENTS. 137 

be found, pressure upon which will immediately cause cessation of 
the spasm. These points usually correspond to the situation of the 
Valleix points in trigeminal neuralgia. They may occur in every 
branch of the trigeminus, on the skin of the face, and in the cavity 
of the mouth. Remak has called attention to the fact that press- 
ure upon, or galvanic irritation over, the transverse processes of 
the cervical spinal column will sometimes arrest the spasm. Occa- 
sionally these pressure-points, which should be diligently searched 
for, may be found in more remote parts of the body. The action 
of pressure upon the points of arrest is much more pronounced in 
blepharospasm than in the more diffused cases. Under these 
circumstances the eyes will frequently fly open as though a spring 
had been touched liberating a shutter. 

The facial convulsions are in some cases limited to isolated 
muscles ; the orbicularis palpebrarum is especially prone to suffer, 
giving rise to the affection known as blepharospasm^ whose history 
was so elaborated by Von Graefe. The contraction is tonic, 
causing a complete closure of the eye, and consequent blindness. 
This is accompanied by innumerable bizarre grimaces, due to the 
efforts of the antagonistic muscles to overcome the force which is 
closing the lids. The tonic spasm may last* for but a few mo- 
ments, or it may continue almost without relaxation for weeks. 
It is prone to be excited by sudden exposure to light, by loud 
noises, or by any emotion. Blepharospasm is usuall}^ coincident 
with photophobia, and is generally reflex, due to some local in- 
flammation of the eye, or more rarely to carious teeth, to ulcera- 
tions in the mouth or throat, or to some other local irritation at a 
point distant from the eye. 

Another form of local spasm of the orbicularis oculi is the 
so-called nictitating spasm. It differs from blepharospasm chiefly 
in being clonic, so that the eye is rapidly opened and shut, instead 
of being held firmly closed. 

Vaso-motor and trophic changes very rarely, if ever, accompany 
facial spasm. 

Tonic spasm of all the facial muscles is spoken of by some 
writers, but in the majority of cases such alleged tonic spasm has, 
in all probability, been due to contractures following paralysis. 
(See Contractures.) 

In any case of facial spasm it is the duty of the practitioner to 



138 DIAGNOSTIC NEUROLOGY. 

endeavor to discover the cause. It may be^ first, reflex ; secondly, 
rheumatic; thirdly, due to hysteria, or to a general neurotic con- 
dition of the system ; fourthly^ the expression of a centric disease. 
The reflex spasm has been noted as being produced by facial sur- 
gical traumatisms, by tumors and disease of the bone, by enlarged 
lymphatic glands, parotid abscesses, diseases of the teeth and jaw, 
and various irritations of more distant portions of the body, such 
as uterine disease, intestinal worms, etc. In many of these cases 
the spasm should perhaps be considered as due to a direct irrita- 
tion of the facial nerve rather than as reflex. The nature of a 
reflex facial spasm is to be recognized by finding the point of 
irritation and noting the effect of its removal. 

I have used the term rheumatic to cover the class of cases in 
which the spasm is precipitated by exposure to cold and wet. It 
is probable that under these circumstances there is a neuritis, and 
that the nerve-trunk would be found sensitive on pressure. I 
have, however, no personal evidence to offer on this point, and 
have not been able to find any in literature. 

The hysterical form of the disorder is to be recognized by the 
presence of a neurotic or hysterical temperament and the absence 
of other cause. As already stated, this form of the spasm is par- 
ticularly apt to involve contiguous muscles, and it is especially 
characteristic that at times spasms of these muscles should re- 
place those of the facial territory. 

Spasm of the facial nerve due to centric disease is the result of 
an irritating lesion existing either in the neighborhood of the 
facial nucleus or in that of the nerve-trunk. It is especially apt 
to occur in syphilitic disease. The serious nature of organic facial 
spasm is usually recognized without difiiculty by its being asso- 
ciated with occasional epileptic attacks, or with other evidences of 
cerebral implication. Not rarely the centric facial spasm ought 
to be looked on as part of a Jacksonian epilepsy. 

Finally, there is a residuum of cases of facial spasm in which 
no cause can be assigned for the spasm. Under these circum- 
stances there is probably some degeneration of the facial nucleus. 

Spinal Accessory Spasm. — Spasm of the muscles supplied 
by the spinal accessory nerve constitutes the Tig rotatoire of 
French and the Tic-krampf of German writers, and is not ex- 
tremely rare. In the majority of cases it is unilateral, but not 



MOTOR EXCITEMENTS. 139 

infrequently it is bilateral, and implicates the muscles of each side 
of the neck. The sterno-cleido-mastoid muscle may be affected 
either alone or as a co-sufferer with the trapezius muscle. By the 
contraction of the sterno-cleido-mastoid of one side the occiput is 
drawn backward and towards the affected muscle, so that the chin 
is thrown upward and towards the normal side. At the same time 
the head is bent over so that the ear is brought nearer the clavicle. 
When the trapezius is alone affected, the head is drawn backward 
and towards the contracted muscle without rotation of the chin, 
whilst the shoulder is raised and the scapula brought nearer to 
the vertebral column. 

Contraction of the trapezius without implication of the sterno- 
cleido-mastoid is unusual, but it is common for the trapezius to 
escape in part or entirely. When the muscles are simultaneously 
contracted, the movements produced by each of them are combined 
in various proportions, according as one muscle or the other is 
more violently affected. 

The spasms come on in frequently-repeated paroxysms, which 
are often frightful in their violence. They usually cease during 
sleep, and are intensified by emotion or any kind of disturbance. 
In the severest cases the patient is disabled during the paroxysm 
from talking or performing any action. There is almost invariably 
more or less suffering during the paroxysm, and in some cases the 
pain is terrible. It seems to me that there are as clearly two forms 
of tic rotatoire, a painful and a non-painful spinal accessory spasm, 
as there are of tic. It is very rare to find points upon which 
pressure will arrest the paroxysm ; on the other hand, I have 
noted painful points, pressure upon which induced paroxysms 
of horrible intensity. There is a very distinct tendency for the 
spinal accessory spasm to overflow into the spinal cervical region ; 
and in a case in which I had both spinal accessory nerves cut the 
convulsions continued, although in a much modified form, evi- 
dently through the spinal nerves. 

The causes of spinal accessory spasm are usually extremely 
recondite. It probably may be reflex, and it certainly may be 
hysterical, but in the great majority of cases no point of irritation 
can be found, and no evidences of centric disease can be discov- 
ered. The extreme obstinacy of the affection indicates, however, 
that it is due to some obscure degeneration of the nerve-centres. 



140 DIAGNOSTIC NEUROLOGY. 

"Wry-Neck. — Tonic spasm of the sterno-cleido-raastoid muscle, 
and consequent fixed torticollis, or wry-neck, is usually rheumatic. 

I have seen a severe torticollis produced in children by enlarge- 
ment of the cervical glands, probably as the result of a direct irri- 
tation of the nerves. In some of these cases care is necessary to 
avoid being misled into believing that a centric disease exists, be- 
cause the pupil upon the diseased side may be affected by press- 
ure upon, or by irritation of, the sympathetic nerve fibres, which 
accompany the carotid artery and its branches through the skull 
and orbit into the eye. 

TREMORS. 

Tremors may be defined to be involuntary oscillatory move- 
ments which are produced by somewhat rhythmical alternate con- 
tractions of antagonistic nmscles and do not prevent voluntary 
actions. They are normally present, to a certain degree, in many 
neurotic persons, in whom they are increased by excessive mental 
or physical work, by the free use of tobacco, coffee, or tea, and by 
any other action or agency which tends to increase '' nervousness.'^ 

Pathological tremors may be due to certain poisons, to the al- 
terations of old age, to the so-called Parkinson's disease or paraly- 
sis agitans, to multiple cerebro-spinal sclerosis, to general paralysis 
of the insane, and, in rare cases, to focal diseases of the brain. 

Senile Tremors. — Senile tremors usually are developed at an 
advanced age, although in some cases they are manifested in early 
middle life, particularly under an hereditary influence. Their or- 
dinary development is gradual. In most cases they are first seen in 
the muscles of the neck, or in the arms, from which they slowly 
spread to other portions of the body. During absolute repose 
they are naturally absent ; but even the effort of extending or sup- 
porting a limb causes them to reappear. They are usually increased 
by excitement, mental or physical. The most characteristic symp- 
tom is the oscillation of the head, which is often accompanied by 
tremblings of the tongue and of the lower jaw. In advanced cases 
the muscles of respiration participate so that the speech is affected. 
Senile tremors are usually accompanied by a very gradual failure 
of muscular power, but there is no true palsy. 

Toxic Tremors. — According to Lafont, lead-poisoning is some- 
times accompanied by tremors, whose origin is indicated by their 



MOTOR EXCITEMENTS. 141 

being much worse at the end of the day. It is aiBSrmed that in 
some cases these saturnine tremors are exceedingly violent and 
acute. Muscular contractility is said to remain intact. 

Tremors are said also to be a marked phenomenon in chronic 
mereurial poisoning. Hallopeau states that in workers in mer- 
cury they are a very constant symptom, and are transmitted to 
the children. They usually begin as a very fine tremor of the lips, 
tongue, and extremities, gradually becoming more intense until 
they are excessive. In some cases they have come on suddenly. 
During repose the affected limbs are quiet, but the moment any 
attempt is made towards voluntary movement the tremors appear : 
so that there is a simulation of multiple cerebro-spinal sclerosis. 
The tremulousness of the tongue is said to be exceedingly constant, 
and to produce a peculiar staccato and hesitating speech. The 
head is quiet until very late in the disorder. There is usually 
insomnia; sometimes there are true clonic convulsions. The 
diagnosis must rest chiefly upon a knowledge of exposure to 
mercurial vapors. 

Tremors are constant and characteristic in chronic alcoholism. 
They resemble somewhat those of old age, but their true nature is 
revealed by their being markedly worse in the early morning ; by 
their being increased by abstinence from drink and quieted by a 
potation ; and by their accompanying other symptoms of chronic 
alcoholism. (See page 27.) They are commonly worse in the hands 
than in any other portion of the body. In old drunkards the alco- 
holic tremor merges insensibly into the phenomena of senility. 

Paralysis Agitans. — The characteristic phenomena of pa- 
ralysis agitans, or Parkinson^s disease, are tremors, progressive 
failure of power in the affected muscles, slowly-developed moder- 
ate rigidity, and, in the most advanced stages, peculiar alterations 
in the habitual positions of the body and in the gait. 

Paralysis agitans usually comes on insidiously and gradually, 
although in some cases the symptoms have developed at once after 
a sudden fright or other emotional storm. The attention of the 
patient is first attracted by a tremor in the hand or foot, or even 
in one finger or toe. This tremor at first is transitory, can be 
controlled, at least temporarily, by an effort of the will, and is 
suspended by voluntary movement. Little by little, without any 
fixed method of progression, it involves more and more of the 



142 DIAGNOSTIC NEUROLOGY. 

body, becomes more and more settled, and at last continues 
throughout all the waking hours, during repose as well as during 
action, and cannot be controlled at all by the will. It often passes 
up the arm first invaded, and then descends to the lower limb of 
the same side, constituting the hemiplegic form ; or it may com- 
mence in a leg and pass across the body to the opposite leg, and 
produce a paraplegic variety. Finally, all portions of the body 
are affected except the head. The face is very rarely attacked 
by the tremors, although in the later stages it puts on a peculiar 
fixed, immovable, usually melancholic expression. According to 
Charcot, the head is never affected, — any apparent trembling of 
it being due to the transmission of motion from the trunk. 
This absolute assertion is, however, not correct, as I have seen 
typical cases of paralysis agitans in which the muscles of the neck 
and the head were in constant tremor; and Westphal {Chariti 
Ann., 1877, p. 405) is said to have reported similar cases. Loss 
of power in the lips seems to be not infrequent in the advanced 
stages, so that there is a tendency to dribbling of the saliva, a 
tendency which is also in part due to the peculiar prone position 
of the head. The speech becomes a little slow and labored, but is 
not profoundly affected : neither eating nor swallowing is inter- 
fered with. 

The tremors themselves are short, very rapid, and in some cases 
distinctly rhythmical, especially in the fingers, where they may as- 
sume somewhat the appearance of voluntary actions, as though the 
patient were rolling something between the digits. I have noticed 
in some cases a distinct tendency of the tremors to alter their 
rapidity in accordance with any rhythmical sound, so that their 
rapidity could be regulated, without the patient^s being conscious of 
it, by altering the rate of vibration in the interrupter of a faradic 
battery. A peculiar rigidity of the muscles is characteristic of the 
advanced stages. There are no violent contractures, but a char- 
acteristic fixation of the part. To this statue-like rigidity is, at 
least in some measure, due the position of the patient. In stand- 
ing the trunk is inclined forward, with the face looking obliquely 
downward ; the forearms usually flexed somewhat upon the arms ; 
the hands a little bent upon the forearms, and the fingers partially 
closed, so that the hands assume a position similar to that in 
which the pen is held : hence the term of " writing hand'^ as given 



MOTOR EXCITEMENTS. 143 

by Charcot. The same tendency to flexion of the legs exists^ so 
that in standing the knees are bent. Occcasionally, peculiar dis- 
tortions of the hands or other portions of the body may be met 
with. On attempting to restore the normal position of the parts, 
the muscle usually offers but little resistance until the restoration 
is nearly perfected. 

The power of making momentary muscular efforts diminishes 
very slowly in paralysis agitans, but even early in the disease 
fatigue follows moderate exertion, so that there is soon a great loss 
of endurance. In not rare cases there is a marked tendency to 
festination in the walk, — i.e., to a progressive increase in the ra- 
pidity of the gait. The man seems to be in continual danger of 
falling forward when attempting to walk, so that the leg has to be 
thrust forward more and more quickly in order to prevent top- 
pling over, and the walk becomes more and more rapid, and in a 
little while breaks into a run, which grows faster and faster, until 
the patient either falls or arrests his course by seizing hold of some 
stationary object. The peculiar position of the body would appear 
to be the cause of the accelerated gait, the head being thrown so 
far forward as to bring the centre of gravity beyond the line of 
the feet. That the festination depends upon something more than 
this is, however, shown by the fact that there are cases in which 
the tendency is to run backward instead of forward. Moreover, 
a very markedly bent position is not incompatible with a normal 
gait. 

Sensation is not profoundly affected, and in some cases there is 
very little suffering. Usually, however, especially as the disease 
advances, there is a perpetual sense of fatigue in the affected mus- 
cles, which may amount to a severe aching. Very frequently the 
patient complains of an habitual feeling of excessive heat, which 
also may be manifested by a continual sweating. This sensation 
of heat does not depend upon any elevation of the central bodily 
temperature, which is of normal intensity. The studies of Grasset 
and Apollinario, however, indicate that there is an elevation of 
the temperature of the external surface of the body. These ob- 
servers found that whilst the temperature of the surface of the fore- 
arm in the normal individual was 33.6° C, in a case of paralysis 
agitans placed under similar conditions of clothing and exposure 
the temperature was 36.8° C. 



144 DIAGNOSTIC NEUROLOGY. 

The urine has been chemically analyzed by Regnard {Progrh 
M^d,, 1877), who found the urea normal, the sulphates less than 
normal. According to Cheron {Progr^s Med., 1877, No. 48), 
there is a constant increase in the quantity of the phosphates, which 
is characteristic, and may even precede the development of the 
tremors. This important observation needs confirmation. 

The course of paralysis agitans requires many years for its full 
development, but if the patient does not die of an intercurrent 
disorder he passes into a condition of hypochondriasis, great 
depression of spirits, loss of intellectual power, general failure of 
nutrition, marked emaciation, loss of digestive power, and general 
marasmus, and at last dies of exhaustion, the end often being j 
hastened by bed-sores or other local ailments. 

Multiple Cerebro-spinal Sclerosis. — The tremors which are 
present in multiple cerebro-spinal sclerosis are characterized by 
their complete absence not only during sleep, but also during 
repose. In most cases the quiet sitting with the hands in the lap 
suffices to put aside all trembling, but in other instances it is neces- 
sary to put the patient to bed in order to get a muscular rest suffi- 
ciently absolute to allow complete cessation of the tremors. When 
any movement is made the tremors appear first in the part that is 
in action, but in most cases they in a little time spread throughout 
the body, so that the simple effort of writing may produce trem- 
blings in every part of the organism. In contradistinction to or- 
dinary cases of paralysis agitans, the tremors especially affect the 
head. They are always associated with a more or less pronounced 
palsy of the affected part. 

In most cases there are some indications of disturbance of cere- 
bration, such as loss of memory, or of the power of fixing the at- 
tention. As the symptoms depend upon the existence of isolated 
patches of chronic inflammation or sclerosis in the brain and 
spinal cord, it is apparent that the cerebral and spinal symp- 
toms which accompany the tremors must vary almost indefinitely 
according as the exact seat of the sclerotic patches varies. The 
degree of mental impairment is in direct proportion to the amount 
of invasion of the upper brain-centres. Mental symptoms may be 
very slight, or even altogether absent, but hallucinations and other 
symptoms of insanity have been noticed. The usual tendency 
is, however, towards failure of the mental powers, or even com- 



MOTOR EXCITEMENTS. 145 

plete amentia, rather than towards active insanity. Charcot states 
that in about three-fourths of the cases of cerebro-spiual sclerosis 
vertigo is present. Usually objects seem to be whirling around with 
great rapidity, and the individual himself feels as though he were 
revolving. Not rarely the vertigo is so severe that the patient has 
to lay hold of something in order to maintain the standing position. 
Closely allied to the vertigo are the apoplectic attacks, which are in 
advanced cases quite frequent. These attacks usually come on 
suddenly without aura or other warning. Sometimes there is com- 
plete loss of consciousness, in other cases there are convulsive seiz- 
ures, which may resemble those of major epilepsy. Commonly the 
patient recovers rapidly from such attacks, but occasionally a par- 
tial hemiplegia is left for a few hours, or even a few days. Death 
may take place during a paroxysm, when no lesion will be found 
in the brain to account for the acute symptoms. At the time of 
the attack the pulse is usually accelerated, and, according to the 
researches of Westphal, there is a rapid and characteristic rise of 
the central temperature. In the hours following the first apoplec- 
tic invasion a temperature of 102° F. has been noticed, and twenty- 
four hours later 104° F,, the patient finally recovering. It is 
asserted that when the temperature passes above 105° F. death 
almost inevitably occurs. Charcot affirms that the congestive 
attack of disseminated sclerosis can be diagnosed from a true 
apoplexy occurring in this or any other affection by paying atten- 
tion to these temperatures, — in cerebral hemorrhage any rise of 
the bodily temperature being always preceded by a fall, which is 
wanting in congestive apoplexy. 

Ocular symptoms are very frequently present in multiple cere- 
bral sclerosis. Nystagmus has been noted in a number of cases. 
Diplopia occasionally exists ; but amblyopia is a much more fre- 
quent and persistent symptom. 

In many cases symptoms due to invasion of the pons or medulla 
are present. A peculiar enunciation is almost characteristic of the 
disease, the patient hesitating in the articulation, although not 
distinctly stammering, and having special trouble with the con- 
sonants Z, j9, and g. The words are pronounced in a low, hesi- 
tating manner, with a certain regularity of accent and pause, some- 
what after the method of school-boys in reading Latin poetry : 
hence this peculiar speech has been spoken of as "scanning.'^ 

10 



146 DIAGNOSTIC NEUROLOGY. 

Tremulousness of the tongue, with wasting, has been noted in 
some instances: in other cases all the paralytic and atrophic 
symptoms of the so-called progressive bulbar palsy are present. 

The spinal symptoms may simulate those of any form of chronic 
sclerosis, or may consist of a mass of commingled types. Thus, 
if the sclerosed patches happen to be in the posterior root-zones, 
the fulgurant pains, disturbances of co-ordination, loss of the 
knee-jerk, and the other symptoms belonging to locomotor ataxia 
may be present. When the lateral columns of the cord are in- 
volved, contractures of the muscles with resultant deformities, ex- 
aggerated reflexes, and the other symptoms of lateral sclerosis may 
be well developed. If the patches have involved both the lateral 
columns and the contiguous gray matter, the symptoms resemble 
those of amyotrophic lateral sclerosis. Muscular contractures, 
heightened reflexes, and wasting of the affected muscles are pres- 
ent. The gait varies according to the spinal distribution of the 
sclerosed foci. It may be that of locomotor ataxia, it maybe that 
of lateral sclerosis, or it may be a grotesque combination of the 
two. 

The course of multiple cerebro-spinal sclerosis is usually slow. 
Five, six, or even eight years may be required for the wearing 
out of the prodromes. The intellectual disturbance finally deepens 
into dementia, the general loss of power into profound paralysis, 
the difficulty of speech into an unintelligible grunting, the mus- 
cular wasting into excessive trophic disturbances, with abscesses, 
ulcerative destruction of the internal mucous coats, and perhaps 
death from septicaemia. In the great majority of cases, however, 
the patient perishes of some intercurrent disease, especially of 
pneumonia, phthisis, or dysentery. 

The diagnosis of multiple cerebro-spinal sclerosis is generally 
to be based upon the appearance of tremors during action and 
the slow failure of muscular power, since years may elapse before 
the occurrence of any other symptoms. When the patches of 
sclerosis are confined to the spinal cord there are no tremors : i.e., 
in multiple spinal sclerosis tremors are not present. 

CHOREA. 

Choreic movements may be defined to be irregular move- 
ments produced by independent contractions of single or associated 



MOTOR EXCITEMENTS. 147 

groups of muscles not vibratory in character, and more or less 
simulating purposive movements, but never forming a complicated 
series of apparently purposive actions. They may vary in inten- 
sity from the slightest, irregular movements of the fingers or 
toes, or even a mere condition of excessive muscular activity re- 
sembling restlessness, up to the most severe and violent motions. 
They may be confined to a single group of muscles, under which 
circumstances they may be considered as forms of local spasm, or 
they may involve associated groups of muscles, or the entire mus- 
cular system of the organism. When, however, the whole body 
is affected, the muscular contractions do not take place regularly 
or consentaneously, but momentarily here and there. They are 
often under the control of the will for a short period of time, but 
always assert themselves in a few minutes, and in many cases can- 
not be controlled at all. 

The choreic movement is usually irregular and not at all rhyth- 
mical, but in some cases is more or less regular, and it may be 
entirely rhythmical. Rhythmical choreas more or less closely 
resemble tremors, differing chiefly in that the movements are 
much slower and more extensive. 

When the choreic movements involve all parts of the body the 
patient may be said to be suffering from general chorea."^ When 

* The names of St. Yitus's Dance, tlie Dance of St. JoTin, Chorea Minor 
and Chorea Major, and Chorea Germanorum, have been so much used and 
with such different meanings that it seems necessary to say a few words here 
in regard to the signification with which they will be employed in this book. 
It appears that the Phrygian Bacchantes, in their wild worship, were affected 
with furious uncontrollable automatic movements, accompanied by more or 
less disturbance of consciousness, and it is certain that the sect of the Suffi, 
in Persia, shortly after the origin of Mohammedanism, were accustomed in 
their sacred ceremonies to pass into a condition of raging excitement, with 
furious dancing, convulsive tremblings, and even general convulsions. About 
the year 1000 a sect of the Suffi found numerous followers and imitators 
throughout Asia Minor, Persia, and Egypt, and even in Greece. In Christian 
lands the so-called Dance of St. John was already at the time of the Crusades 
an observed custom ; and when the influence of the Suffi spread itself by the 
returning waves of the Crusades, the epidemics of religious excitement and 
automatic dancing became more and more violent. It was not until the out- 
break, in 1418, of a fresh epidemic in Strassburg, that the term Dance of St. 
Yeit began to be freely applied to these religious disorders, a name which 
appears to have had its origin largely in the fact that in these later epi- 
demics children were especially affected. St. Yeit was a boy who, born in 



148 DIAGNOSTIC NEUROLOGY. 

the choreic movements are fixed in one part, the term local chorea 
may be used. 

GENERAL CHOREA. 

Acute general chorea is usually due to St. Vitus's dance. 

St. Vitus's Dance. — St. Vitus\s dance is a non-febrile disease, 
generally occurring in children, which is characterized by the pres- 
ence of choreic movements usually involving all portions of the 
body, although liable to aflPect especially one extremity or one 
half of the body, associated with a condition of general lack of 
tone, and often with a distinct loss of muscular power. The 
invasion of this disease may be sudden or gradual. The attack 
may come on in the midst of apparent health, but ordinarily it is 
preceded by languor, irregular action of the gastro-intestinal tract, 
and a pronounced nervous irritability. The motor disturbance 
may be first indicated by a peculiar restlessness of the child, who 
is not rarely punished for fidgeting. The true choreic movements 
usually appear first in the fingers, and shortly afterwards in the face, 
and spread until they involve the whole body. In severe attacks 
the arms are in almost constant movement, the fingers opening 
and closing, the wrists flexing and extending, and the elbow-joints 
in almost incessant activity, so that every imaginable position of 
the hand and arm is rapidly taken and lost. During the violence 
of the disease it is impossible for the child to control the move- 
ments of the arm sufficiently to dress or feed himself, or to perform 

the island of Sicily, suffered martyrdom in the year 303 during the persecution 
of Diocletian, and whose body, carried hither and thither for a considerable 
length of time, found its final resting-place in the cloister of Korvey. 

By Paracelsus these epidemics were called Chorea Sancti Yiti, and Chorea 
Lasciva. The disease of childhood now known as St. Yitus's dance has no con- 
nection either etiologically or in its nature with these epidemics, but modern 
custom enforces the application of the name to it as used in this book. By 
many German writers the affection of childhood is known as Chorea minor, 
whilst the term Chorea major, or Chorea Germanorum, is used to express 
affections more or less closely resembling in their phenomena those of the 
epidemic furies of the Middle Ages. By some German writers any very bad 
case of ordinary chorea is spoken of as Chorea magna. In the present work 
the term Chorea major is used with its more limited signification, as express- 
ing a disease in which occur paroxysms of movements that are automatic and 
beyond the immediate control of the will of the patient, although closely re- 
sembling voluntary acts in their apparent purposiveness and in their sequence. 



MOTOR EXCITEMENTS. 149 

any act requiring precision of motion. At this time the legs 
are similarly affected, so that walking is gradually interfered 
with, or may be rendered impossible. The steps are irregular, 
jerking, often with lateral movements, now rapid, now slow, and 
if progression occur at all it is zigzag and uncertain. The face 
and head are no less affected : there is a constant, ever-changing 
distortion of the countenance, giving rise to fleeting expressions 
of sadness, terror, grief, rage, etc., and to grimaces innumerable. 
The mouth is opened and shut, the corners jerking up and down: 
the tongue is protruded, or sometimes moved rapidly in the mouth 
so as to produce a peculiar clacking sound. Articulation grows 
indistinct, the child speaks irregularly and badly, perhaps only in 
monosyllables, and finally the voice may be converted into a suc- 
cession of irregular unintelligible sounds. In very bad cases mas- 
tication becomes almost impossible, and even the muscles of deglu- 
tition are involved, so that the child is unable to swallow at the 
proper moment, and the food is spluttered and spilled about. The 
head itself is moved rapidly to and fro, backward and forward, 
sometimes laterally, sometimes in perpetual rotation. In the most 
violent cases all the muscles of the body are in a condition of 
furious action. The rolling, twisting movement of the trunk, and 
the perpetual beatings and thrashings of the extremities, render 
it almost impossible for the patient to lie in bed unless fastened 
down, and the utmost care is necessary to prevent severe bruises 
and excoriations of the skin. 

The respiratory muscles are the last to be affected, but cases 
have been reported in which hiccough, crowing inspiration, irregu- 
lar respiratory rhythm, and other evidences of choreic action of 
the respiratory muscles were abundantly present. The choreic 
movements cease at night, or at least during sleep, but in the 
most severe cases by keeping the patient awake they produce an 
insomnia which constitutes an additional factor in the rapid wear- 
ing out of the strength and the bringing about of a fatal result. 
That the brain-cortex does not entirely escape is shown by the 
peculiar nervous irritability which forms an almost essential 
symptom of the disease. The general intelligence is ordinarily 
well preserved, but there can often be noted a temporary weakness 
of memory, and the loss of the power of fixing the attention upon 
any one subject for a length of time is usually very decided. 



150 DIAGNOSTIC NEUROLOGY. 

Hallucinations are very rare, and usually indicate that a chorea 
is hysterical. They may, however, occur in typical St. Vitus's 
dance. In fatal cases the mental disturbances are very pronounced ; 
there may be even an acute dementia : sometimes the patient is 
seized with maniacal delirium, which is always of exceedingly 
serious import. 

The muscles of organic life may participate in the choreic 
disturbance. This is especially true of the heart. Chronic 
valvular lesions are frequent among choreic patients, and an 
acute endocarditis occasionally occurs during an attack of St. 
Vitus's dance ; but cases are not rare in which mitral or even 
aortic murmurs are heard during an attack wliich are not due 
to any organic lesion of the heart and are not haemic in their 
origin. This is shown by the fact that these murmurs occur 
when there is no anaemia, that they vary from day to day and 
from hour to hour and at times may be absent, and that when 
the child recovers from the chorea the murmur disappears en- 
tirely. 

Further, fatal cases have been reported in which no valvular 
lesion was found at the autopsy, although marked cardiac mur- 
murs had existed during life. (See Revue mens, des Maladies de 
VEnfance, 1884, ii. 421.) The most rational explanation of these 
murmurs is that they are due to the irregular contractions of the 
chordae tendinese preventing the proper closure of the valves. It 
is the duty of the practitioner always to ausoult the heart of the 
choreic child, and if murmurs be present to decide, if possible, their 
significance. If the history of a previous endocarditis or of pre- 
vious chronic valvular lesions can be obtained, the probabilities 
are always that the murmur is due to an old lesion. The absence 
of such history is, unfortunately, no proof of the previous non- 
existence of cardiac disease. Supposing that the murmur is re- 
cent, it is often a very diflScult matter to decide whether it is 
neurotic or inflammatory. The neurotic murmur rarely, if ever, 
manifests itself in irregularity of the pulse ; it is not associated 
with cardiac pain, nor with elevation of the general temperature. 
If these exist, the diagnosis of acute endocarditis may be con- 
sidered made out. The presence of even one of these symptoms 
should lead the practitioner to treat the case as one of endocar- 
ditis. 



MOTOR EXCITEMENTS. 151 

Whenever a cardiac murmur is heard in a choreic patient, un- 
less its nature be very apparent great care should be exercised in 
the treatment of the case, and a guarded prognosis should be given, 
because a murmur which is apparently neurotic may fail to disap- 
pear after the child's recovery, and because the rapid and complete 
disappearance of a murmur which was apparently organic may 
prove it to have been neurotic. 

Nature and Limitations of Chorea. — The St. Vitus's dance or 
chorea of childhood is a very frequent disorder, having, as al- 
ready stated, clearly-defined clinical characteristics, and would 
seem, therefore, to deserve a distinct place in nosology.* Choreic 
movements may, however, be produced by peripheral irritations, 
and in some cases these movements have been universal, and 
so severe as even to threaten life. Dr. C. Fischer reports {Zeit- 
schrift fur Wunddrzte, 1853, vol. vi. p. 89) the case of a young 
peasant girl, in whom a futile attempt to remove a tooth was fol- 
lowed by the formation of an abscess, and by marked unilateral 
chorea, which lasted two years, until Dr. Fischer removed the 
roots of the tooth, when the movements ceased at once. 

Dr. E. Fischer {Oester. Med. Wochenschrift, 1841, p. 46) re- 
ports a case in which a general chorea ceased at once upon the 
expulsion of a tapeworm. Dr. Edmond Censier records a case 
similar to this in the Gaz. Med.-Chir. de Toulouse, 1877, p. 43. 
The chorea was so violent as to threaten life, and had persisted 
several months, notwithstanding treatment. Amelioration began 
five days after the expulsion of the parasite, was very rapid, and 
resulted in complete cure. In the Journ. de Med. et de Chirurg., 



^ Dr. L. Eousse, in his Thesis (Paris, 1865, No. 252), affirms that in ordinary- 
chorea of childhood points of pain, upon pressure, can be found in nerve- 
trunks where they become very superficial, or where the nerve-trunks 
emerge from bony places, or where the nerve-filaments traverse a muscle to 
reach the skin, or where the finer filaments come near the surface. The pain 
is stated to be quite severe. He asserts that the neuralgic points of Yalleix 
are well marked, and he finds in the head four especial choreic pain points, — 
the occipital point just below the occiput, and cervical superficial points in 
the middle of the neck, a little below the middle of the neck, and upon the 
posterior edge of the sterno-cleido-mastoid, corresponding to the mastoid 
point upon the mastoid process. He further gives a large number of points 
found in connection with other portions of the body, and corresponding to 
the generalizations which he makes as detailed above. 



152 DIAGNOSTIC NEUROLOGY. 

Paris, 1841, is recorded the immediate arrest of a chorea of one 
month^s duration by the expulsion of lumbricoid worms. 

M. Borelli reports (Bulletin de la Soc. de Chirurgie, 1852, p. 
292) the case of a boy thirteen years old, in whom a violent 
chorea which had resisted all treatment for six months was cured 
by the removal of a neuromatous tumor from beneath the foot. 
The movements became less the day after the operation, and by 
the fourth day had ceased entirely. In the Revue de Med,, 1884, 
p. 568, Dr. E. Weill reports a very interesting case in which a 
decided hemichorea was produced by intrapleural injections, the 
movements being upon the same side of the body as the pleurisy. 

Further citations of cases might readily be made, and especially 
an abundance of opinion might be obtained from recognized au- 
thorities, showing the occasional dependence of chorea upon the 
presence of intestinal worms ; but I think enough has been here 
said to prove the existence of a reflex chorea, 

A large number of autopsies have been made upon children 
and adults dead of St. Vitus's dance, and the results have given 
rise to much discussion. In my opinion the older autopsies ought 
to be disregarded. The means of investigation were so imperfect, 
and were so imperfectly used, that the danger of being misled by 
these observations is greater than the chance of receiving enlight- 
enment. Nevertheless, it seems to me that, after throwing over- 
board much rubbish, there remain certain cases in which, after 
properly-conducted autopsies, no appreciable lesion could be found. 
The positive results which have been reached in other cases com- 
prise — first, brain-alteration; secondly, alteration of the spinal 
cord. 

Among the most remarkable papers upon the brain-lesions of 
chorea is that of Dr. Broadbent, who has demonstrated that the 
corpus striatum and thalamus opticus are in some cases the location 
of the lesion. Dr. Broadbent states that a variety of morbid con- 
ditions of these ganglia may produce chorea, but the most frequent 
alteration in his cases was a capillary embolism of the corpus stri- 
atum, thalamus opticus, and their vicinage. A number of autop- 
sies have been made confirming the existence of capillary embolism 
in the brain in fatal chorea, and it would seem as though there 
were an intimate relation between chorea and this condition of 
the brain. The association is too frequent and too peculiar to be 



MOTOR EXCITEMENTS. 153 

merely the result of chance. On the other hand, it is evident 
that in many cases of chorea no such lesion exists. It is absurd 
to suppose that the chorea which is produced in a few hours 
by a fright and is cured in a few days by arsenic is the result 
of so serious an organic lesion as that indicated. Moreover, 
there has been an abundance of autopsies in which capillary em- 
bolism did not exist. Again, as in the case reported by Tuck- 
well, other changes in the brain have been noted besides those of 
embolism.* It must, therefore, be concluded that an acute chorea 
may be intimately associated with minute cerebral embolism, and 
also with other lesions of the brain ; among which lesions may be 
especially mentioned the peculiar alteration of the ganglionic cells 
of the brain noted by Meynert as pervading the whole organ in a 
case of chorea. 

In regard to the spinal cord, the following paragraph from 
the article of Von Ziemssen in his Cyclopaedia sums up the evi- 
dence to the date of its writing, 1877 : '' In the spinal cord alter- 
ations have been repeatedly found, — namely, hypersemia of the 
medulla and the membranes, softening of the cervical and also of 
the 'dorsal medulla (Romberg, Ogle, Gray, Golgi, De Beauvais, 
Hine, Brown-Sequard, Lockhart-Clarke) ; interstitial proliferation 
of nuclei and hyperplasia (Rokitansky, Steiner, Meynert, Elis- 

* In the cases collected by A. Foucherand [La Choree^ Lyons, 1883), in- 
flammatory lesion of tlie central ganglia (opto-striate bodies), and periencepha- 
litis with and without disease of the central ganglia, are represented. Dr. J. 
Muellendorff reports {Deutsch. Archiv fur Med.^ 1880, vol. xi. p. 609) a fatal 
case due to disease of the sphenoid bone, with compression and slight soften- 
ing of the pons. Dr. Hughlings- Jackson details [Brit. Med. Journ.^ 1875, 
vol. i. p. 636) a case in which the symptoms for a considerable time exactly re- 
sembled those of the St. Yitus's dance of childhood, and in which, after death, 
there was found a tuberculosis affecting the surface of the pons, medulla, cere- 
bellum, and the whole base of the brain, also the island of Keil, and neigh- 
boring convolutions, which were softened, as well as the gyrus fornicatus. The 
posterior cerebral arteries were involved, but not the vessels of the corpora 
striata, and no emboli could be detected. Dr. H. M. Tuckwell reports [St. 
Barth. Hosp. Report, 1869, p. 87) a case of chorea in which, after death, there 
was found softening of the right cerebral middle lobe, involving the deeper 
layer of the cortex and the subjacent white substance, and extending into the 
neighborhood of the corpus striatum and optic thalamus. The corpus striatum 
was seemingly not affected ; the optic thalamus was slightly affected in its 
upper and outer aspect. The corresponding region in the left hemisphere 
was likewise soft. 



154 DIAGNOSTIC NEUROLOGY. 

cher), and sometimes serous exudation in the central canal, prolif- 
eration of nuclei in the adventitia of the vessels, and regressive 
metamorphosis in the ganglion-cells (Elischer)/' Since this para- 
graph was penned, spinal lesions have been found in chorea by 
Dr. Dickinson, by Dr. Bury, and by Dr. James Ross. Accord- 
ing to Dr. Dickinson, the part of the cord especially affected in 
the disease is " the central portion of each lateral mass of gray 
matter comprising the root of each posterior horn.'^ 

Dr. Ross says of a case, '^ I was struck with the alteration pre- 
sented by the accessory cells of the anterior gray horns : they ap- 
peared shrivelled, their protoplasm was granular, their nuclei were 
obscured, and many of their processes were indistinct or absent." 

Without indulging in further quotations, it may be stated that 
we have the evidence of at least five or six different observers as 
to the alterations of the spinal ganglionic cells in acute human 
chorea, and that in numerous other cases these alterations in all 
probability existed, but were overlooked. I do not mean to assert 
that an appreciable lesion of the spinal cells is always to be found 
in St. Vitus^s dance; indeed, I am confident that the disease may 
prove fatal without such lesion. Nevertheless, I am well assured 
that such alterations are very frequent in fatal cases, and that in 
not a few instances they have been overlooked because not ap- 
preciated and sought for. 

There is a form of chorea which is not uncommon in the young 
of certain of our carnivorous domestic animals. I have never 
seen a case in herbivora; but Professor Huidekoper, of the Vet- 
erinary Department of the University of Pennsylvania, informs 
me that he has treated the disease in calves. The relations of 
animal chorea with the chorea of childhood have been consider- 
ably discussed, with difference of conclusions. Except in the case 
of contagious diseases, it is impossible to determine with absolute 
positiveness that a certain disease in the animal represents a cer- 
tain disease in man ; but to my mind it is plain that if canine 
chorea be not the same disorder as the St. Vitus^s dance of child- 
hood it is very closely allied to it. 

It is true that the movements in canine chorea are usually 
rhythmical, whilst the movements in the child are ordinarily not 
so, and much has been made out of this difference. I have, how- 
ever, seen dogs in which the movements were not rhythmical, but 



MOTOR EXCITEMENTS. 155 

had all the gaucherie of the chorea of childhood, and in some cases 
of children the choreic movements approximate the rhythmical 
type. The points of resemblance in the two affections are close 
and striking. In each disease it is the young that are especially 
attacked; in each the chief symptoms are those of disordered 
motion; each affection is connected with a constitutional disorder 
(rheumatism in the child, and distemper in the dog) ; in each 
the movements can be temporarily inhibited by the will, are not 
accompanied by disorder of sensation, and are associated with 
loss of power and lowered general nerve-tone; finally, in each 
disease arsenic is recognized as the standard remedy. 

The important point in this matter is that it is proved (see paper 
by author. Therapeutic Gazette, May, 1885) that the movements 
in animal chorea originate in the spinal cord. My own studies 
of the spinal cords of choreic dogs have shown that the basal lesion 
is a peculiar condition of the ganglionic, or multipolar, cells. 
Gowers and Sankey have noted an infiltration of the gray matter 
with leucocytes, especially in the neighborhood of the vessels, and 
a similar condition has been seen by M. Pierret (Foucherand, La 
Choree, Lyons, 1883), but, for reasons given in detail in my paper, 
it seems to me that the change in the cells is the main lesion, and 
in this I have been recently confirmed by Professor Horsley, of 
London. Further, this is in accord with the previous observation 
of Professor Putnam, of Boston. 

When the animal was killed in the very beginning of the attack, 
the cells showed no change; a little later the only alterations in 
the cells were the very frequent absence of the nuclei, the failure 
of granulations in the protoplasm, the loss of power to take stain- 
ing fluids, and rarely the occurrence of sharply-defined vacuoles. 
Then the processes began to drop off; and finally it was found that 
the places of the cells were occupied by irregular, globose, crum- 
pled-looking masses, without sharp outline, and taking carmine 
staining very faintly. No granulations, no nuclei, no processes, 
were apparent. These masses represent the cells in the last stages 
of degeneration. 

There is probably at first only a functional disturbance of the 
spmal cell. The distinction between functional and organic dis- 
ease is a purely arbitrary one. Functional movements are the 
results of nutritive changes, and a functional disorder is one in 



156 DIAGNOSTIC NEUROLOGY. 

which the nutritive changes have occurred, but have not suf- 
ficiently advanced to be recognized by our comparatively gross 
methods of study. The structure of the ganglionic nerve-cells is 
so complex in its ultimate nature, and yet so simple in its micro- 
scopic appearances, that it may be permanently and very seriously 
altered without leaving a physical trace which we can recognize. 
The first change in canine chorea is an altered nutrition — i.e., func- 
tional excitement (or depression) — of the multipolar cells of the 
spinal cord. This altered nutrition may continue until the struc- 
ture of the cells is entirely destroyed, but it may never go beyond 
a condition of change so non-apparent as to be unappreciable to 
us. The studies of Dr. Putnam show that in the kitten the brain- 
cells suffer like those of the spinal cord, and it is most probable 
that in animal chorea the movements originate in the altered 
nutrition of the spinal cells, but that throughout the nervous 
system the ganglionic nerve-masses suffer, so that the disorder 
is really a condition affecting not merely the spinal but rather 
the whole nervous system. 

The bearing of what has just been said upon the question as 
to the nature of St. Vitus's dance is very obvious. 

The marked tendency of the choreic movements to affect one side 
of the body or one limb has led many observers to confine their 
careful examinations to the brain, this hemiplegic or monoplegic 
tendency being believed to show that the movements originate in 
the brain and not in the spinal cord. A clinical study of the 
various human affections of the motor ganglia of the cord shows, 
however, that in such disorders spinal monoplegias are not at all 
uncommon, and that in some cases hemiplegias may be seen. In 
many cases of chorea of the dog this localization of the move- 
ments in one limb or in one side of the body is quite pronounced; 
indeed, this was the case in dogs in which I positively determined 
the spinal cord to be the source of the movements: it cannot there- 
fore be considered that a hemiplegic chorea, much less a mono- 
plegic one, is necessarily of brain-origin. 

The similarity of the lesions which have been recently noted 
in the ganglionic cells of the spinal cord in fatal cases of 
human chorea to those which I have found in the dog is very 
apparent, and increases the probability that the two affections 
are essentially the same disorder. Whether this be so or not, 



MOTOR EXCITEMENTS. 157 

it is proved that choreic movements in the dog may originate 
from a diseased condition of the ganglionic spinal cells, and it is 
contrary to all known physiological laws that what in this respect 
is true of the dog should not be true also of the human being. 
That a purely spinal chorea may exist in man is further shown 
not only by what has already been said^ but also by the case re- 
ported by Foucherand^ in which in a chronically choreic child the 
brain was found to be healthy but the cord full of minute inflam- 
matory foci. Further, since a diseased condition of the spinal 
ganglionic cells has been found in several cases of St. Vitus's 
dance, it must be allowed that such diseased state is at least one of 
the fundamental pathological alterations of human chorea. It is 
perfectly clear, on the other hand, that the disorder is not confined 
to these multipolar cells. The researches of Dr. Putnam, already 
quoted, show that in the cat alterations may be found, at least in 
some cases, in the brain ganglionic cells, and every clinician knows 
that the cerebral functions are often profoundly aflfected in the 
choreic child. The will, the intellect, and the emotional facul- 
ties are all prone to show the presence of an abnormal influence 
in chorea ; and it seems, therefore, that we must consider that in 
the choreic child the ganglionic cells in the whole cerebrospinal 
system suffer, and that this alteration is the base of the disease; 
in other words, the pathology of the St. Vitus^s dance of childhood 
may be said to be a diseased condition of the ganglionic structures 
of the cerebrospinal axis, ivhich abnormal state may exist imthout 
alterations of structure suffi^cient to be determined by the microscope, 
or may go on until it is accompanied by marked structural lesions. 
Further, this condition must be looked upon as one of lowered 
tone, and it must be allowed that it may be produced by various 
causes, but is not likely to occur in persons of robust nervous 
system. The vital choreic depression of the nerve-cells may be 
the result of emotional disturbance, as in the chorea produced by 
fright. It may be the result of the influence of the rheumatic 
diathesis or poison upon the affected tissues. To the greatly de- 
pressed condition of the spinal ganglionic cells is due the fact that 
in almost all severe cases of St. Vitus^s dance in children some 
degree of general or local muscular weakness exists. This in many 
cases amounts to a partial palsy, which may take the hemiplegic, 
paraplegic, or monoplegic form. The paralysis is never complete 



158 DIAGNOSTIC NEUROLOGY. 

unless^ indeed, the chorea be associated with, or dependent upon, 
some organic lesion of the nervous system, and it almost invaria- 
bly is recovered from without diflSculty as the choreic symptoms 
subside. 

On the other hand, it is very certain that minute brain-embo- 
lisms and other lesions exclusively of the brain will produce 
a chorea. Not only does this rest upon an abundance of clinical 
evidence, but M. Raymond has produced chorea in dogs by in- 
juring the posterior part of the foot of the corona radiata in the 
brain. It would appear, therefore, that lesions of any of the gan- 
glionic cells connected with the direct cerebral or pyramidal trad may 
cause chorea ; and that there are various forms of acute chorea, or, 
to state it more correctly, that there are various acute diseases in 
which chorea is a prominent symptom. 

We must conclude that chorea is no more uniform in its signifi- 
cance than is paralysis, and that it may be due — 

First^ to the chorea of childhood, or St. Vitus's dance. 

Secondly^ to reflex irritation. 

Thirdly^ to organic disease of the nerve-centres. 

Fourthly, to pregnancy. 

Fifthly, to hysteria. 

Sixthly, probably to conditions of the nerve-centres not as yet 
made out. 

Sufficient has been said in regard to choreas of the first three 
classes. 

Chorea of Pregnancy. — A form of chorea the immediate cause 
of which is uncertain is that which occasionally occurs during 
pregnancy. It is frequently a very severe affection, in which the 
movements are so excessively violent and incessant that they de- 
prive the sufferer of sleep and rapidly cause a fatal exhaustion. 
There seems to be on the part of obstetric authorities a tendency 
to believe that this chorea is a reflex neurosis ; but the clinical his- 
tories of the cases show that a remarkable proportion of the 
patients had suffered from chorea during childhood, that some- 
times the symptoms are mild, closely resembling those of the St. 
Vitus^s dance of childhood, and that they are often accompanied 
by the peculiar muscular weaknesses seen in that disorder. (Cases, 
Dr. Fehling, Archiv fur Gynaecol, 1874, vol. vi. p. 137.) More- 
over, in a number of instances distinct organic lesions of the brain 



MOTOR EXCITEMENTS. 159 

or of the spinal cord have been found after death. These lesions 
have consisted of slight hypersemia of the brain and very great 
effusion in the right ventricle {Obstet. Journ, of Gh^eat Britain^ 
vol. iv. p. 80) ; of softening of the corpus callosum, medulla ob- 
longata, and cerebellum [Obstet Trans, ^ Lond., vol. x. p. 159); and 
of softening of the cord {ibid,^ pp. 163, 164, etc.). Further, if the 
symptoms of chorea of pregnancy were purely reflex, removal of 
the foetus should bring quiet. Yet in six of the seventeen fatal 
cases collected by Dr. Barnes {Obstet, Trans, ^ 1869) no effect 
was produced by emptying the uterus ; also in the case reported 
by Dr. Goodell {Amer. Journ, of Obstet,, 1869) removal of 
the child was without influence. The facts that are at present 
known concerning the causation of chorea of pregnancy may be 
summed up in a single sentence. There are usually a predispo- 
sition to chorea, inherited or acquired, inanition of the nervous 
system mcident to the hydraemic state of the blood during preg- 
nancy, and various potential peripheral irritations, especially in 
connection with the sexual organs. The most rational explanation 
of the chorea of pregnancy is that it varies in its immediate pathol- 
ogy, the pregnancy simply producing a condition of the nervous 
system which predisposes it to be thrown into an active chorea by 
various exciting causes. 

Hysterical Chorea. — A general or local chorea may be pro- 
duced by hysteria. The movements may be limited to a single 
limb, or they may be hemiplegic or paraplegic, and not rarely 
they involve the whole body. They are often disorderly and ir- 
regular and closely simulate those of ordinary St. Vitus^s dance. 
Under such circumstances their true nature is to be recognized by 
the existence of marked concomitant symptoms of hysteria, and 
especially by the occurrence of occasional or persistent rigidity of 
the affected muscles. The true choreic neurosis may, however, 
coexist with, or perhaps depend upon, the hysterical neurosis, so 
that it would often be equally correct to speak of a patient as 
suffering from hysterical chorea or from choreic hysteria. 

It is especially in hysteria that the peculiar brusque, rapid mus- 
cular contractions occur to which the name electric chorea has been 
given by the French writers. (See Thesis, F. Colaneri, Paris, 
1884; also A. Guertin, Paris, 1881.) In this disorder the whole 
body, or any portion of it, is the seat of more or less rapidly 



160 DIAGNOSTIC NEUROLOGY. 

repeated, violent muscular spasms, resembling those produced by 
a sudden severe electric shock. It is asserted that electric chorea 
may be a symptom of chronic alcoholism : thus, in the case re- 
ported by M. Landouzy {Soc. de BioL, 1873, May 31), an habitual 
drunkard, aged thirty-seven, suffered from manifestations of this 
form. When the man was lying on his back the legs would be 
flexed upon the thigh, and the thigh upon the pelvis, with slight 
abduction, then suddenly would be violently extended with a 
rhythmical movement at the rate of sixty or sixty-five times a 
minute. Similar cases are on record ; but I am inclined to believe 
that they are simply instances of hysteria occurring in persons 
who have abused alcohol. 

Rhythmical Spasms. — Choreic movements of hysteria are very 
prone to take on the form of vibratory spasms and to become more 
or less rhythmical. The vibrations may be very rapid. They 
frequently attack extremities distorted by hysterical contractures. 
Thus, in a leg violently flexed by contractures I have seen the 
knees vibrate laterally over a considerable arc at the rate of one 
hundred and twenty times a minute. By tracing a series of cases 
it will be seen that disorderly choreic movements insensibly pass 
into vibrations, and these into true rhythmic spasms. Rhythmic 
spasms may affect any portion of the body. The limbs, normal 
or distorted by contractures, may be agitated with regular move- 
ments. The face may be attacked rhythmically, and facial gri- 
maces, with or without the consentaneous thrusting forward of the 
tongue, occur. Occasionally the muscles of the larynx and of 
respiration are also affected, so that each spasm is accompanied 
by a quick, strange utterance. This rhythmic chorea again passes 
by insensible degrees into the purposive movements of hysteria: 
thus, the rhythmic movements of the legs may give rise, when the 
patient is standing, to a series of rapid changes of posture resem- 
bling the mazourka or other dance. 

LOCAL CHOEEAS. 

Paralytic Chorea. — Of the various local choreas, I shall first 
speak of those which are connected with hemiplegia or mono- 
plegia of cerebral origin. In some cases the movements precede 
the cerebral hemorrhage, constituting the so-called pre-hemiplegio 



MOTOR EXCITEMENTS. 161 

chorea. In other cases they come on after hemorrhage, and are 
spoken of as post-hemiplegic chorea. Not rarely they fail to de- 
velop until the paralysis is distinctly growing less, and, it may be, 
has almost entirely passed off. They may come on gradually or 
suddenly, and are usually most marked in the hand and arm, 
next in the face, and only in rare cases in the leg. The muscles 
which are employed in delicate and complicated movements are 
especially prone to be attacked. The interossei muscles of the 
hand are very frequently affected simultaneously with their asso- 
ciated muscles of the forearm. Almost every variety of motion 
may occur. Sometimes the fingers are rapidly opened and shut. 
Again they are in perpetual flexion or extension. The hand 
itself is often folded and opened out. The wrist may be alter- 
nately flexed and extended, the forearm pronated or supinated, and 
bent or straightened at the elbow; not rarely the whole arm swings 
with an incessant pendulum movement from the shoulder-joint. 

In many cases the movements of paralytic chorea are incessant 
during the waking period, and cease only when the subject goes 
to sleep. Yet in not a few instances they can be partially con- 
trolled by placing the hand in some peculiar position : thus, in a 
case under my own care, when the arm was put behind the body 
partial quiet was obtained; and by fixing the hand against the 
front of the body immediately under the breast, the woman was 
able to control the movements sufficiently to do crocheting. In a 
case reported by Ross, putting the hand in the pocket was suf- 
ficient to obtain rest. 

In some instances the contractions are much more marked 
during voluntary movement than during rest. Indeed, sometimes 
post-hemiplegic chorea is represented simply by a lack of power 

* of co-ordination and control, so that during quiet there is no move- 
ment of the part, but whenever a voluntary act is attempted the 
muscles are thrown into irregular spasmodic action. As pointed 
out by Dr. S. Weir Mitchell, who appears to have been the first 

j clinician to study post-paralytic chorea, there are some cases 

I in which the movements simulate purposive acts. Thus, in 
one of Dr. MitchelFs cases the patient, after an attack of right 
hemiplegia, so incessantly rubbed at the right leg with the right 

/ hand as to wear out the pantaloons. In another case the arm 
was alternately pronated and supinated, and in a third the arm 

11 



162 DIAGNOSTIC NEUROLOGY. 

was swung across the body only during walking, at each step the 
fingers being firmly flexed. 

The movements of the face may affect the whole distribution 
of the facial nerve of the affected side, or may be located simply 
in certain parts of its territory. They give rise to all sorts of 
grimaces and disturbances of expression. 

A very curious association of movements is sometimes seen in 
post-hemiplegic chorea: thus, in a case under my own care, when- 
ever the woman winked a very peculiar spasm occurred, involving 
only a few fibres of the facial nerve, and causing a peculiar dimple 
in the chin. In this case the oculo-motor ganglion had become 
linked to a few cells of one facial nucleus, so that a simultaneous 
nervous discharge from two centres was provoked by one periph- 
eral irritation, or by one effort of the will. 

One form of local chorea, which is usually, if not always, con- 
nected with chronic brain-lesions (especially sclerosis after infantile 
cerebral hemorrhage), is that to which the name athetosis has been 
given. In this the fingers or toes continuously and slowly assume 
various distorted positions, and are only partially under the 
control of the will. The spasms of the muscles of the forearm 
change so slowly that they might well be described as slowly- 
shifting tonic spasms. Athetosis is simply a symptom, not a dis- 
ease, and indeed as a symptom scarcely deserves a name, since it is 
only one of an innumerable variety of post-hemiplegic spasms, and 
is never exactly the same in two cases. 

A condition which occasionally follows a cerebral paralysis, 
and to which the name of hemiataxia has been applied, may be 
considered simply as a very mild form of post-paralytic chorea. 
In this affection disorderly, irregular, spasmodic movements occur 
when voluntary actions are attempted, although there are no mus- 
cular contractions at other times. Speaking of such a case. Dr. 
Mitchell says, ^^ This patient had no involuntary or spontaneous 
movements, no motor disturbance until voluntary acts were at- 
tempted, when they at once became irregular. Those of the hand 
were, as I recall them, so striking that they possessed every clinical 
peculiarity of the chorea of childhood." Other observers attribute 
the irregularity of movement to the loss of the power of co-ordina- 
tion ; but that this is probably not correct is shown by the fact 
noted by Dr. Mitchell, that the movements were as well performed 



MOTOR EXCITEMENTS. 163 

in the dark as in the light. (See also Gowers, Medico- Chirurg. 
Trans,, 1876, vol. Ixx. p. 321 ; Grasset, Progrds Med., viii., 1880.) 
In Dr. Mitchell's case all the extremities seem to have been some- 
what affected, but the right hand was the most so. At the autopsy- 
there was found very pronounced general atheroma of the cranial 
blood-vessels, and a spot of softening in the right crus cerebri, 
also one in the left corpus striatum. 

Very generally post-paralytic chorea is associated with a more 
or less marked disturbance of sensibility. This hemiansesthesia 
may, however, almost completely disappear, although the choreic 
movements continue as violent as ever. The clinical reports seem 
to show that hemiansesthesia is not so absolutely essential, even to 
the post-hemiplegic chorea of adults, as is stated by some writers. 

The accumulating clinical records confirm the original supposi- 
tion of Dr. Mitchell, that post-paralytic chorea is most frequent 
when the attack of hemiplegia comes on in early life : hence the 
disease is especially marked in children suffering from paralysis 
the result of sclerotic patches in the brain, such as has been fully 
discussed in the chapter on Palsy. (See p. 75.) It should, how- 
ever, be distinctly understood that this form of local chorea may 
develop at any age. 

The particular seat of the lesion in post-hemiplegic chorea, as 
first stated by Charcot, and especially developed in the thesis of 
his pupil, Raymond, is in the posterior part of the internal cap- 
sule, in the immediate neighborhood of the lenticular nucleus and 
optic thalamus. The immediate band of fibres of the corona 
radiata especially involved is in front of that connected with and 
covering the posterior end of the optic thalamus. This region, it 
will be remembered, is a very distinct one, having its own artery, 
the posterior optic. Although in many cases of post-hemiplegic 
chorea the lesion is located in the spot designated by the great 
French neurologist, such location is not invariable. M. Demange 
{Rev. de Med., March, 1883, p. 377), after reporting a case with 
Charcot^s lesion, records one in which there was violent post- 
hemiplegic chorea, and in which the lesion was situated in the 
convolutions. It is a very interesting feature in this case that the 
choreic movements were preceded by epileptiform crises, which 
ceased when the choreic movements developed. The choreic 
movements themselves also disappeared before death. In two 



164 DIAGNOSTIC NEUROLOGY. 

cases of cerebral syphilis^ with presumably cortical lesion, I have 
seen a violent choreiform spasm of the face replace epileptiform 
convulsions, and there is a close analogy between post-hemiplegic 
chorea and Jacksonian epilepsy. Dr. Demange reports a case in 
which hemiplegia was associated with severe tremblings, like those 
of paralysis agitans, and the lesion was situated in the lenticular 
nucleus. This form of tremor might, however, be considered 
distinct from true post-hemiplegic chorea, but in the Bulletin of the 
Anatomical Society of Paris, 1879 (vol. liv. p. 748), is recorded a 
case in which a true post-paralytic chorea was found to depend 
upon a softening of the brain on the level of the first convolution, 
involving the whole thickness of the external capsule, as the sole 
lesion. 

Dr. F. Greiff (-irc/i. /lir Psychiatrie, 1883, xiv. 598) reports a 
case where the only lesions were in the cerebral cortex and in the 
pons ; further, that local chorea may be spinal is shown by the 
case detailed by Eisenlohr (quoted by Foucherand, p. 58), in 
which choreic movements had existed in both arms from birth, 
and yet careful microscopical examination failed to detect anything 
abnormal in the brain, but revealed sclerotic nodules in the 
cervical cord. 

The evidence seems to me sufficient to show that a lesion any- 
where in the pyramidal tract — i.e., in the direct line from the 
brain-cortex to the motor spinal cells — or in the motor spinal 
cells may produce a localized chorea. When, however, a post- 
paralytic chorea is associated with hemiansesthesia, the lesion is 
probably at the position designated by Charcot. The cases re- 
ported by Demange separate themselves from those of Charcot 
in the absence of sensory disturbance. 

Chorea of Stumps. — A form of local chorea to which the 
name Chorea of Stumps was given by Dr. S. W. Mitchell con- 
sists in its mildest form of a condition of unstable equilibrium in 
the muscles of a surgical stump, so that under the stimulus of voli- 
tion, emotions, or even changes of the weather, they will contract 
irregularly and spasmodically. In the next degree of intensity 
spontaneous twitchings and movements occur without any per- 
ceptible immediate cause. In severe cases the violence of the 
movements is such that the stump is perpetually rotated, jerked, 
vibrated, whirled in all directions, thrashed about, etc. The 



MOTOR EXCITEMENTS. 165 

spasms in some cases are entirely irregular, in other instances they 
come and go with clock-like monotony. Appearing first in the 
peripheral muscles of the stump, they are liable to spread until 
they involve the whole limb, or even, as in a case which I reported 
in detail in the Philadelphia Medical Times, vol. x. p. 53, one side 
of the body. In this case the clonic spasms of the flexors of 
a leg-stump were at the rate of a little over a hundred a minute, 
each drawing the end of the stump towards the thigh over an 
arc of from two to four inches. Occasionally there were also 
spasms of the extensors, and more rarely choreic spasms of the 
glutei and other muscles moving the thigh. In the forearm the 
choreic movements occurred from eighty to ninety times a minute. 
The biceps muscle of the upper arm every now and then was 
seized with spasms, which for a time were rapidly repeated. The 
muscles of the shoulders were rarely affected, but the patient 
stated that sometimes they, with the lateral muscles of the trunk, 
were very active. Tliere were also slight choreic twitchings of 
the neck-muscles, and occasionally very decided clonic spasms of 
the face. The right side of the body was always quiet. Usually 
in the chorea of stumps the movements cease during sleep ; but in 
the case just spoken of the stump was never quiet, and the patient 
always, when attempting to go to sleep, placed the arm under his 
head, so as to hold it still. In most cases, when stump chorea 
has once set in, it continues indefinitely ; usually it is not associ- 
ated with pain or tenderness. In my own case very careful inves- 
tigation was made of the nerve-trunks, both by pressure and by 
the electrical current, without eliciting any abnormal sensitiveness. 
Occasionally a neuralgic stump is also choreic. The pathology 
of chorea of stumps remains uncertain. After amputations the 
nerves are prone to undergo inflammatory changes, which may 
gradually creep up until they involve the spinal cord. The ab- 
sence of local tenderness in many choreic stumps indicates that 
the movements are not due to neuritis ; but the only recorded case 
I know of in which, by section of the nerve, light was thrown 
upon the question whether the spasm is or is not due to a per- 
ipheral irritation is one reported by Dr. Langsdorf (quoted by 
Mitchell), in which the chorea coexisted with evident neuritis, 
as was shown by pain and tenderness, and was cured by re- 
amputation. 



166 DIAGNOSTIC NEUROLOGY. 

Chorea in Internal Inflammations. — There have been re- 
ported from time to time cases in which violent, brusque, wide- 
spread muscular contractions have been developed in the course 
of acute internal inflammation, such as a pleurisy, or a bronchitis, 
or a pneumonia. It is possible that the choreic movements in 
some of these cases were reflex. The i^aramyodonus multiplex of 
Prof. Friedreich, of Heidelberg, appears to be of this character. 

Habit Choreas. — There remains a series of local choreas in 
which no definite cause can be assigned for the spasmodic move- 
ments; which movements, also, in a great many cases, closely 
simulate purposive acts. It is probable that in many of these 
cases the movements originated during childhood in a frequently 
repeated purposive act, which soon gained the force of a bad 
habit, and, not being corrected by the will of the child, grew, 
in a neurotic temperament, into a fixed custom of the nervous 
system : hence the term Habit Chorea of Dr. S. Weir Mitchell. 
A brow may be lifted at intervals, a shoulder shrugged, an eye 
winked, a jaw dragged forward, a trick of gesture incessantly 
repeated, even a cough or a snuffle perpetually indulged in. In 
the beginning these habit choreas are not purely voluntary move- 
ments, although controllable by a strong effort of the will, but are 
allied to the ordinary St. Vitus's dance of childhood, and are 
greatly benefited by hygienic treatment and by the use of arsenic, 
as well as by moral means. They finally become so fixed that they 
are entirely beyond the control of the patient or of any medicinal 
treatment. Under these circumstances it would appear as though 
the affected nerve-centres had acquired the habit of discharging 
themselves at regular intervals independently of any control of 
the will. The habit chorea has a distinct tendency not only to 
become more and more uncontrollable with years, but also to 
increase in its range. 

CONTRACTURES. 

Contractures may affect one extremity, one lateral half of the 
body, or the lower extremities, when they are spoken of re- 
spectively as monoplegic, hemiplegic, and paraplegic. They may 
also be confined to a group of associated muscles, or to a single 
nerve-distribution, or they may exist in scattered unconnected 
groups of muscles : in a word, as contractures are frequently late 



MOTOR EXCITEMENTS. 167 

conditions of paralyzed muscle^ they follow paralysis in their 
distribution. 

The existence of a contracture is so apparent that it is recog- 
nized at once ; but much diagnostic skill is sometimes required to 
determine the cause of it. 

Contractures may be clinically divided into those which occur 
independently of movement, — class A, — and those which take 
place only during voluntary movement, — class B. 

Contractures of class A may be due to — 

1. Cerebral affections. 

2. Complete loss of power in one of two sets of antagonistic 
muscles. 

3. Chronic neuritis. 

4. Irritation of the motor nerve-roots by organic disease of 
the spinal membranes or of the vertebrae. 

5. Sclerosis of the spinal cord, especially affecting the lateral 
columns. 

6. Hysteria. 

Contractures of class B are represented by one affection, Thom- 
sen's disease. 

ContradureSy Class A. 

Cerebral Contractures. — Contractures from cerebral hemor- 
rhage may be clinically divided into three sets : 

First Those which come on at the time of the hemorrhage, 
and which may be known as immediate rigidity. 

Second, Those which appear from fifteen to thirty days after 
the hemorrhage, and which may be known as early rigidity. 

Third. Those which develop after the lapse of some months, 
and constitute late rigidity. 

In each of these forms the contracture follows the position of 
the paralysis, except that the face is rarely implicated, and that 
the arm is usually more affected than the leg. 

Both immediate and early rigidity are the results of irritations 
of fibres of the pyramidal tract. In their lightest form they may 
be easily overlooked, but they are to be recognized by the sense 
of resistance experienced when passive motions of the affected 
parts are made. They are always associated with an excessive 
faradic and reflex excitability of the affected muscle, and usually 
disappear during sleep. As they are the indication of inflam- 



168 DIAGNOSTIC NEUROLOGY. 

matory changes occurring somewhere in the pyramidal tract, 
they are of serious import. 

Late rigidity is due to a descending degeneration of the fibres 
of the pyramidal tract, and corresponds in its manifestations with 
the contractures of lateral sclerosis, from which it is to be distin- 
guished by its history, and by its being hemiplegic or monoplegic. 
The reflexes are always exaggerated. There is finally a progres- 
sive atrophy of the muscles, which in the course of years may 
almost entirely disappear. As has already been stated in the 
article on Paralysis, the so-called spastic palsy of childhood is 
often a form of cerebral hemorrhage with secondary degenerations 
and consequent late rigidity. 

Contractures in Infantile Paralysis. — In acute poliomyelitis 
the contractures and consequent deformities are very slowly de- 
veloped. The paralyzed muscles remain limp until they are 
converted into fibrous cords, the contractures being exclusively in 
their antagonists, — i.e., in the non-paralyzed muscles. Neurolo- 
gists differ as to whether the distortions are produced by the 
shortening of the muscles, or the shortening of the muscles by 
the distortions. Some believe that the non-paralyzed muscles 
meeting with no resistance gradually undergo alteration and con- 
traction, whilst others believe that the shortening and contraction 
of the muscles are the result of the settling of the limb towards 
the origin of the muscle, which causes the muscle to shorten itself 
for purposes of adaptation. The practical point is, that the non- 
paralyzed muscles gradually atrophy and grow shorter. 

Mening'eal Rigidity. — One of the most characteristic symp- 
toms of basal cerebral meningitis is stiffness of the muscles of the 
neck, due to spasm of the muscles, which, in extreme cases, may 
cause marked retraction of the head. In the mildest cases there is 
merely immovability of the head, and even this may be wanting; 
but when the head is raised from the pillow by the hand, a marked 
sense of resistance will be felt. This form of tonic spasm is not, 
strictly speaking, a contracture, but in chronic spinal meningitis 
the persistent rigidity of the muscles, especially of the legs, may 
well be mistaken for an organic contracture. The limbs under 
these circumstances are drawn up on the body, the legs are bent 
upon the thighs, and the feet are somewhat extended. Relaxation 
does not occur during sleep or anaesthesia. 



MOTOB EXCITEMENTS. 169 

Some little difficulty may be experienced in diagnosing between 
the rigidity of chronic spinal meningitis and other organic or 
hysterical contractures. The symptoms are due to inflammation 
propagated from the spinal membranes along the nerve-sheaths^ 
so that the spasms are extraordinarily intense, and are associated 
with violent pains, caused by irritation of the posterior nerve-roots. 
In rare cases, when the disease is located about the cauda equina, 
the exudation may produce sufficient pressure upon the nerves to 
cause paralytic symptoms. Under such circumstances an error in 
diagnosis is especially liable to occur. 

In both organic and hysterical contractures pain is produced by 
an attempt to straighten the legs; but when the spasms are the 
result of a spinal meningitis, any attempt to overcome them pro- 
duces an agony which is much greater than that caused in other 
contractures. In one or two cases I have been enabled to make 
the correct diagnosis by noticing the existence of an excessively 
severe girdle pain. In simple myelitis the girdle sensation may 
be very pronounced, but it does not rise to the point of agony, as 
may happen when it is the result of a secondary neuritis of the 
abdominal nerves. I have noticed, in cases which I believed to 
be chronic spinal meningitis, tenderness over the large nerve-trunks 
of the legs, probably the result of a descending neuritis. In a 
doubtful case aid in diagnosis might be obtained from this, as in 
myelitis the inflammation travels down the nerve-trunks very 
slowly, if at all. 

Localized chronic spinal meningitis not due to a disease of the 
vertebrae is usually syphilitic. The diagnosis between it and 
cancerous tumor must be carefully made. (See pages 50 and 61.) 

Contractures of Neuritis. — Contractures do not appear to be 
a marked symptom of chronic neuritis : when they occur their 
nature is to be recognized by their history, and by the existence 
of tenderness over the affected nerves. They may exist in isolated 
groups of muscles, or they may be symmetrically arranged. 

Hysterical Contractures. — Permanent contractures may be 
caused by hysteria. They may affect one or several limbs, and 
may be monoplegic, hemiplegic, or paraplegic, — the paraplegic 
form being, on the whole, the most frequent. 

The contractures may affect only single groups of muscles, or 
may attack a series of muscles surrounding the joints, and in this 



170 DIAGNOSTIC NEUROLOGY. 

way an hysterical club-foot, or an hysterically contracted hand, or 
an hysterically fixed and apparently inflamed joint, may be pro- 
duced. In the wide-spread general contracture pain is a rare 
symptom, but in these localized contractures, especially in the 
neighborhood of joints, it is very frequent. 

The general contractures usually develop suddenly, often fol- 
lowing a hystero-epileptic or other violent hysterical attack, and 
may remain for years, to disappear as suddenly as they appeared. 
In most cases the shortening of the muscles is excessive, and the 
rigidity absolute, so that the distortion is extreme : thus, in a 
contracture affecting the lower extremities, the patient usually lies 
with the legs rigidly extended, the feet inverted, the heels drawn 
up to the greatest extent possible, and the toes flexed. In the 
early periods of the contracture the reflexes are distinctly exag- 
gerated, the faradic contractility of the muscles is increased to a 
greater or less degree, and the nutrition of the part is good. When, 
however, the contractures remain for a long time, the muscles 
undergo gradual wasting, and lose gradually their faradic contrac- 
tility. 

Unless a history of sudden occurrence of the contractures can 
be obtained, the positive diagnosis of the hysterical contracture is 
often exceedingly diflScult, even in the earlier stages of the disease. 
It has been asserted that the occurrence of ankle-clonus proves the 
existence of organic disease ; but this is not correct. 

In many cases an analgesia and an anaesthesia coexist with con- 
tractures. Under these circumstances the diagnosis may be aided 
by the relative positions of the paralysis and anaesthesia : in 
cerebral organic hemiplegia the contractures and hemianaesthesia 
are usually on the same side ; in hysterical cases the two symp- 
toms may coexist, or may be upon opposite sides of the body. If 
contractures are associated with a generalized anaesthesia or anal- 
gesia, they are hysterical. 

The difficulties of diagnosis are well illustrated in a case which 
was under my care in the Philadelphia Hospital. The woman 
suffered from pronounced spinal curvature, due to organic verte- 
bral disease, with contractures of the legs and gross ankle-clonus. 
No other hysterical manifestations were present, and there was no 
reliable history of the case. The diagnosis was made of organic 
degeneration of the spinal cord, secondary to an original transverse 



MOTOR EXCITEMENTS. 171 

myelitis; but after being in the hospital for many months the 
patient recovered in a few days. 

The question of diagnosis is further complicated by the fact 
that organic contractures may supervene upon the hysterical 
variety. Charcot reports the case of a woman in whom contrac- 
tures of all four extremities developed suddenly and continued 
for ten years, with but few temporary remissions. After the last 
seizure the contractures remained until death, and at the autopsy 
symmetrical sclerosis of the lateral columns was found to extend 
almost the entire length of the cord. In one of my own cases, 
contractures which had apparently been originally hysterical did 
not relax during anaesthesia, and were accompanied with much 
atrophy of the affected muscle. In accordance with the rule laid 
down by Charcot, that whenever marked atrophy of the muscles 
and persistence of the contractures during anaesthesia are present 
organic degeneration of the spinal cord has probably set in, the 
diagnosis in my case would be lateral sclerosis following an 
originally hysterical contracture. 

To sum up, hysterical contractures are to be distinguished from 
their organic prototypes by— 

First. Suddenness of development. 

Secondly, An hysterical history. 

Thirdly. Presence of anaesthesia or other distinct hysterical 
symptoms. 

Fourthly. Absence of wasting or other changes in the muscles. 

Fifthly. Sudden remissions of the contractures. 

Sixthly. Absence of various symptoms of organic, spinal, or 
cerebral disease sometimes present in organic contractures. 

Seventhly. Disappearance of the contractures during anaesthesia. 

Lateral Sclerosis. — A very common form or cause of con- 
tractures is sclerosis of the lateral columns of the spinal cord, 
either focal or continuous. In the great majority of cases the 
legs are affected solely, giving rise to the so-called spastic para- 
plegia. But sometimes, especially in focal disease of the lateral 
columns, the sclerosis may be so limited in the upper portions 
of the cord that the motor symptoms are confined to one or more 
of the upper extremities. The diagnosis of lateral sclerosis rests 
upon — 

First Slowness of development. 



172 DIAGNOSTIC NEUROLOGY. 

Secondly. Gradual loss of power^ associated with spasm and 
heightened reflexes. 

Thirdly. Absence of girdle sensation, of pain, or of disturbance 
of sensation; of paralysis of bladder or rectum, of trophic changes, 
and of disorder of co-ordination. 

As lateral sclerosis has already been fully considered (see p. 66), 
it is only necessary here to state that in some cases violent tremors 
develop in the leg during walking and other voluntary move- 
ments of the feet. 

Contractures, Class B. 

Thomsen's Disease. — In Archiv fur Psychiatric, 1876, vol. 
vi. p. 762, Dr. Thomsen described in detail a group of symptoms 
with which some thirty-five of his relatives were afflicted, and 
which are now believed to be characteristic of a distinct affection 
commonly known as Thomsen's disease (^myotonia congenita, 
Strumpel). Cases of similar character were described by Charles 
Bell as early as 1830, and more recently by Benedict in 1868, 
by Leyden in 1874, and especially by Seeligmiiller in the last- 
named year.* The essential symptom of the affection is that when 
voluntary movement is attempted the muscle is thrown into a 
condition of tonic spasm, which may spread to the entire vol- 
untary muscular system, and last for several minutes, before there 
is sufficient relaxation for the patient to command his actions. 
In some of the cases the symptoms have dated from infancy, in 
others they appear to have developed in late childhood or early 
manhood. Almost invariably the subjects are healthy men, who 
are apparently extremely muscular, but who, on trial, possess very 
little endurance, and also comparatively limited muscular power 
for momentary exertion. The affection is markedly hereditary, 
and in most of the reported cases clear evidences could be obtained 

^ The literature of this subject up to the fall of 1883 was very thoroughly 
collected by Dr. Mobius {Schmidts Jahrh.^ cxcviii. 236). Since this time the 
most important papers known to me are to be found as follows : Union Med., 
1888, xxxvi. 905; 1885, xxxix. 50; Bev. de Med., 1883, iii.1064; Oaz. Hebd. 
de Medecine^ 1884, xxi. 18; Brain^ vii. 105-131; Canada Lancet^ Toronto, 
1884-85, xvii. 71 ; Alieiiist and Neurologist^ v. 619 ; Centralblatt fur Ner- 
venheilkunde, 1885, viii. 122, 193 ; Berliner Klin. Woche?ischrift, 1883, 
xxii. 605. 



MOTOR EXCITEMENTS. 173 

of near relatives of the patient having suflFered from similar 
symptoms. In Thomsen^s family there was a distinct history of 
attacks through five generations. Several of his own children 
were affected, and of his thirteen brothers and sisters seven had 
developed very decided symptoms. In a remarkable proportion 
of the cases the disease has been detected in military recruits, who, 
at first believed to be excessively awkward at drill, were finally 
found to be really unable to control their muscular movements. 
Such was the nature of the case reported by Seeligmiiller. Peters 
tells of a soldier twenty years old who, when commanded to march, 
would remain immovable for a length of time as if rooted to the 
ground, then, with awkward struggling movements of his arms 
and legs, he would free himself, and after staggering a few paces 
would be able to go on regularly ; but, even after he had regained 
control of his muscles, if he attempted to run he would directly 
fall to the ground in a condition of rigidity which involved his 
whole muscular system, including the tongue and face. When 
he laid hold of an object he w^as unable to let it go; and thus it 
was with almost any muscular act. In a case which came under 
my care in this city, the patient complained chiefly that, when 
going up-stairs, after three or four steps his advancing leg, as he 
raised himself on it, would be seized with a painless but irresistible 
tetanic spasm, which would for several moments entirely prevent 
progression. The tendency to tonic contractures is invariably 
increased by fatigue, often by emotional excitement, and usually 
by exposure to cold; warmth, the frequent repetition of move- 
ments, and moderate exercise tend to lessen it. Pressure upon 
the arteries or nerves does not, as in tetany, produce muscular 
contractions. (Marie, Rev. de Med,, 1883, iii. 1069.) 

The contractions may be confined to a single group of muscles 
in direct relation with those which are primarily caused to con- 
tract by the will. Thus, in a case reported by Mobius, the 
muscles of the leg were the only ones that ever suflFered from 
cramp, which first appeared after excessive fatigue. The case 
also differed from the ordinary one in the lack of the enlargement 
of the muscles. Nevertheless, the fact that the patient's father 
had also suffered marks the disease as the hereditary aflTection. 
Dr. L. Deligny [Union Mid,, 1885, vol. xxxix. p. 50) details 
a case in which a brusque turning of the head would give rise to 



174 DIAGNOSTIC NEUROLOGY. 

a spasm of the acting sterno-mastoid muscle. Mastication would 
produce stiflPness in the jaw-muscles. In some cases of Thomseu's 
disease a sudden push during walking is sufficient to bring on 
absolute universal stiffiaess ; in others, sneezing, coughing, swal- 
lowing, crying, even winking, will produce a paroxysm. A con- 
traction which involves the whole body is affirmed to commence 
usually in the legs themselves, and to spread to the arms, and 
finally to the muscles of the hip. This succession probably depends 
upon the fact that the attacks are generally precipitated by the 
movements of walking. 

Vizioli studied the muscular contraction with the dynamograph 
(Alienist and Neurologist, vol. v. p. 621), and portrayed its pecu- 
liarities in graphic curves. ^' He observed that by making the 
patient hold the hand open, and ordering him to close it, there 
passed some five seconds before the movement was accomplished; 
if the hand was partially closed instead of being widely open, — 
i.6., if it was put into the state of flexion, — the patient on being 
told to close it fully did so almost immediately, without the voli- 
tion being sensibly retarded. This contraction was, however, 
marked by a line composed of many ample oscillations (tremor 
oscillatorius). The patient took up from five or six to ten 
seconds in opening the hand, when it had been contracted, and 
the relaxing of the flexor muscles was not marked in the graphic 
curve by an almost right line as in the normal state, but by an 
oblique line with irregular oscillations.'^ 

In some cases, as in the soldier studied by Petrone, after the 
first contractures have passed over, there is complete liberty of 
action. 

In a great majority of the reported cases the contractures have 
been painless, or, at least, accompanied with no greater disturb- 
ance of feeling than the sensation of electric currents running 
through the part, a sense of swelling, of pricking, etc. ; but in 
the case already referred to as reported by M. Deligny, four or 
five times a year the patient would suffer a sort of ^^ crisis," com- 
posed of a series of general muscular contractions, which, during 
the period of from twelve to twenty-four hours, recurred at short 
intervals, repeating themselves upon the slightest provocation, and 
were always accompanied with such violent pain that the patient 
would roll on the earth in his agony. 



MOTOR EXCITEMENTS. 175 

The knee-jerk and the true reflexes are usually normal in 
Thomsen's disease, but in some cases a direct blow upon the muscle 
produces a persistent tonic contraction, and Vizioli, and also Marie 
(Bev. de M6d., 1883, vol. iii. p. 1069), have noted increased knee- 
jerk. Passive movements are at least in some cases performed 
without resistance (Arch, de NeuroL, January, 1883). To inspec- 
tion the muscles almost invariably appeared to be hypertrophied, 
but careful examinations made by Jacusiel, Ponfick, and Petrone 
have demonstrated that their structure is normal. In a single 
case Peters found evidences of atrophy in the lower portion of 
the deltoid. The integrity of the muscular structure is further 
shown by their electro-contractility being normal, save that mo- 
mentary application of the faradic current produces a tetanic 
contraction which may last five and one-half seconds (Seelig- 
miiller) after the removal of the current. In one case Bigou- 
roux believed that the tetanic contraction of closure was greater 
at the anode than at the cathode. The muscles of involuntary 
life do not appear to suflPer, although in a case reported by Ballet 
and Marie the larynx was often the seat of the spasm. The 
pathology of Thomsen^s disease is unknown. No autopsies have 
been reported. 

AUTOMATIC MOVEMENTS. 

Automatic Movements are complicated movements, closely re- 
sembling the purposive actions of ordinary life, which take place 
independently of the will of the patient. 

Cases of automatic movements are best studied for clinical 
purposes under the headings of — first, those in which the 
actions are produced by an impulse arising spontaneously within 
a person, but independently of the will of such person ; secondly, 
those in which the movements occur in response to impulses 
received from without the person. Cases of the first class are 
instances of chorea major. Cases of the second class are psy- 
chical. 

Chorea Major. — In chorea major, or chorea Germanorum, the 
outbreak is usually preceded by prodromes, such as melancholy, 
apathy, feeling of nausea, malaise, cramps, or tonic convulsions, 
disturbances of the circulation, palpitations, etc. The paroxysms 
usually come on with a general excitement, which perhaps ought 



176 DIAGNOSTIC NEUROLOGY. 

to be considered as a form of aura. During the paroxysms the 
affected person dances, sings, springs from the ground, rolls him- 
self from side to side, hammers violently with the hands, stamps 
with the feet, or in a fury of motor excitement whirls with mad 
rapidity until, completely exhausted, he falls to the ground. The 
excitement is not confined to the motor sphere : songs are sung, 
affairs recited, foreign tongues spoken, in a manner entirely beyond 
the normal power of the individual ; events, languages, poet- 
ical quotations, which seemingly never have been engraved upon 
the memory, are recounted or recited in eloquent or incoherent 
ravings. In the height of the attack consciousness is usually lost, 
but sometimes it is in a measure preserved, especially in the spo- 
radic cases. As an instance of the sporadic variety may be men- 
tioned a case reported by Robert Watt, in which a girl ten years 
old turned herself round and round in paroxysms; later, she had 
attacks in which she would roll from end to end of the bed 
violently backward and forward, then, lying upon her back, her 
feet and head would be forcibly jerked together ten or twelve 
times a minute. A single paroxysm of these movements often 
lasted fourteen hours a day. In a more recent case, reported 
by Dr. Bdowenzel (SchmidCs Jahrb., 1874, clxii. 19-:)), a young 
boy, having warning of an attack, would run home from school, 
quickly throw himself upon the bed, spring up and down sud- 
denly innumerable times, stand upon his head, cry out, jump from 
the bed, and run as though in terror round in a circle to the spot 
from which he had started, not rarely in his fury striking his 
head severely against obstacles, and performing many other move- 
ments, until exhausted, when he would sink upon the bed in a 
deep sleep, to awake with full consciousness. 

Mention has already been made of the religious epidemics 
of the Middle Ages, which have been in modern times repeated 
in the outbreaks that have occurred in camp-meetings in the 
United States (especially in Kentucky in the early part of this 
century). Of somewhat the same character are the perform- 
ances of the howling dervishes. The relation of these attacks 
to hysteria is a very clear one. Undoubtedly, in many cases the 
paroxysm is brought on by an effort of the will, precisely as the 
hysterical paroxysm may be induced; but without the hysterical 
excitement the individual would be incapable of performing many 



MOTOR EXCITEMENTS. 177 

of the acts which he does. Further, in some cases of chorea major 
the attacks are really epileptic, being comparable to so-called run- 
ning epilepsy. (See p. 107.) There appears, however, to be a 
remnant of cases which can scarcely be considered hysterical, and 
which certainly are not epileptic. Seemingly of this character 
are the so-called salaam convulsions of children, in which the 
paroxysms recur several times a day, last from a few seconds to 
some minutes, and consist of a bowing forward of the head and 
body perhaps as many as two hundred times. 

Psychical Automatism. — In that form of automatism in 
which the movements are in obedience to impulses from without, 
the abnormal condition is a psychical disturbance, which is to some 
extent illustrated in the phenomena of artificially-induced hyp- 
notism, — a mental condition into the discussion of which I shall 
not here enter. In some rare cases of insanity the sufferer will do 
at once that which either by example or by word of mouth he is 
bidden to do, and will remain almost indefinitely in any position 
in which he is placed or which he assumes at the word of command. 
This condition may be mistaken for catalepsy, but is to be distin- 
guished from it by the fact that consciousness is not lost, and that 
the assumed position is at once departed from when a sharp, 
quick command is given. I have seen this state of pliability 
under command extraordinarily pronounced in a scrofulous child 
of feeble physical organization, but not insane, and of fair mental 
development. 

Miryachit — Latah — Jumpers. — A very curious affection or 
nervous condition, which is perhaps best classed among the psy- 
chical automatic affections, has been noted under various names as 
occurring in Asia, Europe, and America. The essential feature 
of this condition seems to be an extreme excitability of the pa- 
tient, which causes him, upon the least abrupt excitation, such as 
would be produced by slapping him on the shoulder, hallooing at 
him, slamming a door, etc., to jump or perform other violent disor- 
derly acts, conjoined with a condition of the cerebral nervous system 
which necessitates a repetition of voices or sounds [echolalgia), or 
the ejaculation of some word, usually obscene [coprolalgia). In 
some cases the impulse of imitation is so great as to force the vic- 
tim to repeat not only the spoken word but also any act done by 
a by-stander. Yery frequently the sudden nervous excitement is 

12 



178 DIAGNOSTIC NEUROLOGY. 

accompanied by an excessive emotion, especially of fear, although 
such emotion may be entirely foreign to the ordinary nature of 
the individual. The disease appears to be hereditary. It often 
affects various members of several generations of one family. 
According to the elaborate description of M. O'Brien {Jommal of 
the Straits Branch of the Royal Asiatic Society^ Singapore, June, 
1883), in Southern Asia the affection is known by the Malay 
name of lotah. Mr. O'Brien makes four classes of cases: 

Class first, comprising those individuals in whom an unexpected 
noise produces great alarm, with an irresistible impulse to rush 
upon the nearest object, and at the same time forces an exclama- 
tion which is always obscene. 

Class second, comprising those persons in whom certain words 
when suddenly pronounced will produce an excessive paroxysm of 
sudden terror. Thus, in an individual noted for his courage and 
who faced the living alligator without a sign of fear, the sudden 
pronouncing of the word ^^buaya" (Malay for ^^ alligator") pro- 
duced a paroxysm of overpowering terror. 

In class three, the individuals imitate the words, gestures, or 
sayings of those in their neighborhood. 

In the fourth class the individuals become completely abandoned 
to the will of some other person, performing every act, however 
outre or improper, which they are commanded to do by such in- 
dividual, standing on their heads, attacking a spectator, etc. In 
these cases the person who suffers from latah recognizes his enslave- 
ment and is greatly depressed thereby, but is unable to prevent it. 

According to the observations of American naval officers (06- 
servations upon the Corean Coast, United States Naval Department, 
Washington, 1883), an affection allied to latah exists in Eastern 
Siberia, where it is known by the Russian name of miryachit 
In a case seen by the American officers, a pilot would imitate 
against his will with absolute exactitude all the strange gestures 
and acts which were performed in his presence by accident or for 
the determinate purpose of tormenting him, and, even when to 
escape his persecutors the man had locked hiaiself up in the 
pilot-house, he could be heard stamping, pounding on the sides of 
the wall, etc., in exact repetition of acts performed in his hearing 
by persons without. This case plainly represents class three of 
O'Brien. 



MOTOR EXCITEMENTS. 179 

The " Jumpers/^ or '' Jumping Frenchmen/^ of Maine, described 
by Dr. G. M. Beard {Journal of Nervous and Mental Diseases^ vol. 
vii., 1880), seem also to belong in the present category. In these 
persons the hearing of a sudden voice or noise causes a repetition 
of the words or sounds, with the performance of strange antics, 
whilst a loud command seems to be always obeyed. Thus, a 
^^ jumper^' was told to throw a knife which he held in his hand : 
this he did instantly, repeating at the same time the order with 
a cry of alarm, not unlike that of hysteria or epilepsy. Two 
"jumpers^^ standing near each other when commanded to strike 
each other did so with zeal. Dr. Beard tested the echo-speak- 
ing, or repetition, by reading portions of Latin and Greek, when 
the untutored " jumper^^ repeated the sounds of the words as they 
came to him, in a quick, sharp voice, at the same time jumping or 
making some bizarre motion. The slamming of a door, the fall- 
ing of a window-sash, or the sudden scream of a steam-whistle 
produced the same effect as the human voice. In an elaborate 
review M. Gilles de la Tourette [Arch, de Neurol,, vol. viii., 
1884, and vol. ix., 1885) has collected a number of cases occur- 
ring in an isolated manner in Europe more or less closely con- 
forming to the type of the affection just described. 



CHAPTER III. 

xv£jr'^Lj£i!X.£j o . 

Under the general heading of reflexes I propose to discuss 
certain movements of portions of the body which are directly 
produced by external irritations. Some of these movements are 
probably not of the nature of reflex acts, but the term reflexes is 
for our present purpose convenient, and is used with the under- 
standing that its employment does not indicate the correctness 
of any theory as to the way in which the movements are produced. 

The reflexes naturally divide themselves into two varieties, the 
superficial and the deep, — i.e,, those movements which are pro- 
duced by irritations of the skin, and those which are the result of 
irritation of deeper tissues. This division is not only suitable for 
the purpose of the clinician, but appears also to be a natural one, 
as it will be shown hereafter that, whilst the superficial reflexes 
are probably true reflexes, the deep reflexes, so called, are in all 
probability not reflexes at all. 

SUPERFICIAL REFLEXES. 

The superficial reflexes are excited by irritations of the skin 
and mucous membrane, either by tickling, pricking, pinching, or 
gently scratching the surface, or by means of a dry electric brush. 
The nature of these reflexes will be discussed when speaking of 
the so-called deep reflexes. They are to the diagnostician of com- 
paratively minor import, because, unless it be the plantar reflex, 
none of them are always present in healthy individuals, whilst 
some of them are so closely simulated by voluntary acts that it 
may be impossible to decide whether the movement is the result 
of volition or of a reflex irritation. Thus, on tickling of the 
sole of the foot, so long as there is voluntary power and sensation 
a sudden semi-involuntary and yet truly cerebral withdrawing of 
the foot is almost sure to occur. It may be laid down as a general 
rule that the absence of a skin-reflex is of uncertain diagnostic 
import, whilst the presence of the reflex shows the integrity of 
180 



REFLEXES. 181 

the nerve-arc implicated, such nerve-arc being composed of the 
afferent nerve, a section of the spinal cord, and the efferent nerve. 

In enumerating these superficial reflexes I shall follow closely 
the work of Professor Ross. According to the classification used 
by him, there are nine of the skin-reflexes : 

First. The Plantar Reflex, evoked by tickling the sole of the 
foot, whose presence proves the integrity of the reflex arc in- 
volving the lower end of the cord. 

Second. The Gluteal Reflex, consisting of contractions of the 
gluteal muscles produced by stimulating the skin of the buttocks, 
and depending upon the integrity of the arc through the fourth 
and fifth lumbar nerves. 

Third, The Cremaster Reflex, causing the drawing up of the 
testicle when the skin of the inner side of the thigh is stimulated. 
Its presence establishes the integrity of the fii'st and second pair 
of lumbar nerves and their spinal centres. 

Fourth, The Abdominal Reflex, causing contractions of the ab- 
dominal muscles, chiefly the rectus, when the skin of the sides of 
the abdomen is stroked from the ribs downward. It proves 
the integrity of the arcs from the eighth to the twelfth dorsal 
nerves. 

Fifth, The Epigastric Beflex, causing a dimpling of the epigas- 
trium on the stimulation of the same side of the chest in the sixth 
and fifth intercostal spaces, and sometimes even in the fourth. 
This probably requires the integrity of the arcs from the fourth to 
the seventh pair of dorsal nerves. 

Sixth, The Erector-spinal Reflex, causing contraction of the 
erector-spinae muscles when the skin along their edges is stimu- 
lated. It demonstrates the integrity of the reflex arcs in the 
dorsal region of the spinal cord. 

Seventh, The Scapular Reflex, causing contraction of some or 
nearly all of the scapular muscles on superficial irritation of the 
scapular region. It is evidence of the integrity of the arc of 
the upper two or three dorsal and lower two or three cervical 
nerves. 

Eighth. The Palmar Reflex, producing contraction of the flex- 
ors of the fingers on tickling the palm of the hand, and showing 
the integrity of the arcs through the cervical enlargement of the 
cord. This reflex is rarely present in healthy adults. 



182 DIAGNOSTIC NEUROLOGY. 

Ninth, Cranial Reflexes, such as contraction of the palatal mus- 
cles by irritation of the fauces, sneezing by irritation of the nasal 
mucous membrane, cough by irritation of the laryngeal mucous 
membrane, closing of the eyes by irritation of the conjunctiva, 
movements of the iris by light. 

A complete investigation of these cutaneous reflexes in disease 
appears to be still a desideratum. Rosenbach affirms that the 
abdominal reflex, and Jastrowitch that the cremaster reflex, are 
lessened on the paralyzed side in disease of one cerebral hemi- 
sphere. It is, however, a universal rule that the withdrawal of 
the cerebral influence increases the activity of the reflexes, and if 
the superficial reflexes are really lessened in cases of cerebral dis- 
ease it must either be in some indirect manner, or else be due to 
the fact that the lesion which interrupts the motor pathway really 
irritates the white matter below, and through the white matter 
the inhibitory centres in the medulla which control reflex acts. 



DEEP REFLEXES. 

Deep reflexes consist of muscular contractions which are pro- 
duced by blows upon such deep-seated tissues as muscular tendons 
and bones. The most widely known and studied of these myo- 
tatic contractions are those which are produced by striking the 
patellar tendon or the Achilles tendon, the so-called knee-phe- 
nomenon and foot-phenomenon of Westphal, the patellar- tendon 
reflex and the Achilles-tendon reflex of Erb. The name of Erb 
has been shortened by most writers into patella-reflex, and for 
the term foot-phenomenon the name ankle-clonus has been substi- 
tuted. The movements of the ankle differ from those of the 
knee in that they are repeated several times, so as to give rise to 
a succession of movements. This variation is well indicated by 
the employment of the term ankle-clonus, whilst the term knee- 
jerk is coming into vogue as preferable to patella-reflex, as not 
being indicative of any theory as to the nature of the movements. 
It is difficult to understand why we should not have these con- 
tractions in any muscle whose tendon can be readily reached by a 
blow when on a stretch ; but in the ordinary healthy individual 
this form of muscular contraction is not readily demonstratal 
except in connection with the patellar tendon. Occasionally the 



REFLEXES. 183 

biceps of the arm itself may be thrown into movement. In those 
diseases, however, in which the activity of these so-called reflexes 
is exaggerated, contractions are possible in many muscles which 
are not affected in health : thus, it is not rare under the circum- 
stances mentioned for tapping of the tendons of the forearm to 
produce contractions with movements of the fingers. The so-called 
jaw- or chin-jerk, as noted by Dr. Morris J. Lewis, appears to be- 
long to this category. It is best obtained by allowing the jaw to 
hang passively, or by gently supporting it with one hand, whilst 
with the other the blow is struck on the chin with a hammer in a 
downward direction. 

To the tendon-jerks which are not usually demonstrable in nor- 
mal individuals belongs the ankle-clonus. It seems to be aflSrmed 
by Mitchell and Lewis {Med. Neivs, February 13 and 20, 1886) 
that the elbow-, ankle-, and jaw-jerks may be occasionally obtained 
from normal individuals. I have, however, rarely been able to 
demonstrate them, and the ready production of these jerks in any 
individual is a strong indication of the existence of disease. 

Knee-Jerk. — Of the various muscular contractions, to the diag- 
nostician the knee-jerk and the ankle-clonus are supreme in im- 
portance, and I shall discuss them in detail. The condition of the 
knee-jerk can be roughly examined by seating the patient upon 
a chair, with one leg crossed over the other, and then striking 
the patellar tendon below the patella, when a movement of the 
foot will take place. In order, however, to study closely the 
knee-jerk it is necessary to have the leg of the patient bare. The 
blow may be delivered directly on the tendon or upon a rubber 
band placed across the tendon. In some delicate cases the use of 
the finger laid upon the tendon for the reception of the blow may 
be advantageous, as enabling the diagnostician to judge of the 
force of the blow. The blow may be delivered with the edge of 
the hand, with the fingers, or with a small hammer having an 
elastic steel handle and an india-rubber head. The hammer 
often used in percussion may be employed, or preferably an 
oblong narrow head may be given to it. For ordinary diagnostic 
purposes the hand is all-sufficient, and when exaggerated tendon- 
reflexes are to be judged of, a very slight blow may be delivered 
with one finger. In some cases, instead of watching the move- 
ment of the foot, one hand may be laid upon the quadriceps 



184 DIAGNOSTIC NEUROLOGY. 

femoris and its contractions felt. Another method which is occa- 
sionally useful is to allow the patient to sit in an ordinary position 
with the sole of the foot squarely upon the ground, and then to 
judge of the effect of the blow by the movements of the quadriceps 
muscle as felt by the hand or seen by the eye. Dr. A. Money 
practises still another plan for developing the knee-jerk, with 
asserted occasional advantage. The patient being in a sitting 
position, the centre of the instep is taken in the hand and allowed 
to rest upon its palm or surface at a convenient angle of flexion, 
and then the blow is delivered. In all cases it is essential to see 
that the leg be not too much bent, as severe flexion abolishes the 
knee-jerk. In 1883 {Deutsche Archiv fur Klin, Med., vol. xxxiii.), 
Dr. E. Jendrassik discovered that if a severe muscular exertion be 
made at the time of the striking of the patellar tendon the effect 
of the blow is distinctly exaggerated. This observation gave rise 
to a very elaborate investigation of this subject by Drs. S. Weir 
Mitchell and Morris J. Lewis {3Ied. Neics, February, 1886). 

These observers found that the knee-jerk varies in health, and 
is capable of exhaustion by too much use, but may be increased 
by habitual, not-too-often-repeated, excitation. They further dis- 
covered that all volitional acts increase the knee-jerk of either 
leg, such reinforcement lasting for an appreciable time after the 
cessation of volition. If, however, the muscular exercise be suf- 
ficiently violent and lasting, the knee-jerk is finally enfeebled. 
Although the contraction of a muscle may be produced when it 
is in a condition of relaxation, moderate tension increases the re- 
action, and violent tension, such as is produced by fully flexing the 
leg, destroys it. The reinforcement of the knee-jerk by volitional 
act is the immediate result of the volition itself, and not of the 
act which the volition calls into being. For Mitchell and Lewis 
found that when an individual who had lost an arm willed 
movement in the amputated part, the knee-jerk was reinforced. 
Pain and other sufficiently powerful sensory impressions, such as 
are produced by the application of heat or cold to the skin, or 
intense light to the eyes, increase the knee-jerk. It is probably 
owing to the pain caused that faradic currents applied to the body, 
and even galvanic currents, have a stimulating effect upon the 
knee-jerk, an effect which is extremely pronounced when the wire 
brush is employed with faradism on the dry skin. Galvanic cur- 



REFLEXES. * 185 

rents applied to the head increase the knee-jerk, as also do spinal 
galvanic currents of suflBcient power. Pressure upon the sciatic 
nerve sufficient to produce numbness of the leg decreases the 
knee-jerk, as does also profound etherization, whilst inhalation of 
nitrite of amyl has no efiFect. 

Drs. Mitchell and Morris also found that a sufficiently severe 
blow upon any part of a muscle will produce contraction, which 
follows the same laws of reinforcement as does the tendon-reflex. 

Nature of the Reflexes. ^The knee-jerk and all the other so- 
called deep reflexes are apparently not reflex movements, but 
phenomena whose immediate causes lie within the muscle directly 
implicated. Without discussing the evidence in full, it is suffi- 
cient to quote the statement of Dr. Ross, that " there is now pretty 
general agreement among experimenters that the interval of time 
between the blow^ and the contraction is not sufficiently long for 
a reflex act to take place." The contrary to this appears to be 
true in regard to the superficial or skin reflexes, as the measure- 
ments which have so far been made of the time necessary for 
their development coincide with the period required for a reflex 
movement. According to the experiments of Dr. de Watteville, 
about three times as long a time is required for the development 
of the contraction of the quadriceps femoris after an irritation of 
the sole of the foot as for the production of the same contrac- 
tion after a tap upon the tendon. All our present evidence seems 
to show that the contraction of a knee-jerk arises in the muscle 
itself, as the result of the stretching of the tendon which the 
blow causes. It is, however, necessary for the development of 
the so-called deep reflex that the muscle be in a certain condition 
of tone, the term tone being here used to express a degree of 
muscular contraction and irritability, which appears to be the re- 
sult largely of impulses received from the spinal cord, — these im- 
pulses being provoked by peripheral irritations, and being there- 
fore of the nature of minute reflexes. In accord with this theory, 
impulses especially arising in the muscle itself, or in its immediate 
neighborhood, stream up to the spinal cord, and by acting upon 
the ganglionic cells give rise to a continuous series of impulses, 
passing down to the muscle and maintaining it in a certain con- 
dition of activity. Volitional acts evidently increase these mus- 
cular reactions by producing a general excitement of all the motor 



186 DIAGNOSTIC NEUROLOGY. 

centres. The impulse- wave which leaves the brain either puts 
the whole spinal cord in a condition of momentary excitement, 
or, what is more probable, gives rise to numerous minute impulses, 
arising in all parts of the spinal cord and flowing down into all 
parts of the body. A theory which at first thought commends 
itself is that the volitional act depresses the cerebral centres which 
inhibit spinal movement, and consequently increases all reflexes 
by removal of an inhibitive influence : this, however, would seem 
to be disproved by the discovery of Mitchell and Lewis that the 
skin-reflexes are not reinforced by muscular acts or by pains. 
These skin-reflexes are now believed to be of the nature of true 
reflexes, and if decreased inhibition occurred during volitional acts 
they ought to be more strongly reinforced than are the myotatic 
contractions. 

Further, the associated movements of Westphal strongly in- 
dicate the truth of the overflow theory, since they are best ex- 
plained by supposing that in a certain excited state of the spinal 
ganglia the overflow is sufficient to produce definite movements. 
The overflow takes place in health, but only when the gangli- 
onic cells are sensitized by disease does it produce pronounced 
effects. When, by disease, there is an interruption of the con- 
nections which pass through the spinal centres from the afferent 
nerve-endings to the efferent nerve-endings, the tone of the mus- 
cle becomes enfeebled and myotatic contractions cannot be evoked. 
When, on the other hand, there is irritation of the afferent nerve- 
endings, or of the nerve-fibre tracts in the spinal cord, there is an 
exaggeration of the tone-impulses, and consequently of the mus- 
cular tonicity, with a resultant increase in the activity of the 
myotatic contractions. It is a matter of practical importance to 
know whether excitement of the motor nerve-trunks is able to 
increase the tone of the muscle. SuflScient evidence in regard to 
this point is at present not forthcoming, and even with regard to 
the sensory filaments in the nerve-trunk we have not an established 
knowledge ; but my own studies incline me very strongly to the 
opinion that irritation of the sensory nerve does increase muscle- 
tone. 

Whether, as physiologists, we accept or refuse the explanation 
of these myotatic contractions which has just been sketched, as 
practical physicians we must recognize that clinical experience 



REFLEXES. 187 

has proved that the knee-jerk and similar jerks are tests in dis- 
eases of the nerve-tracts whose exact clinical value is well made 
out. 

Constancy of Knee- Jerk. — It is a matter of vital practical im- 
portance to determine the constancy of the knee-jerk in normal 
individuals. Drs. Mitchell and Lewis found that the intensity of 
the knee-jerk is greatly lessened by excessive fatigue. Dr. W. R. 
Gowers [London Lancet, November 7, 1885) believes that it is 
never absent in health. This is certainly contrary to the general 
opinion of observers, for the reaction has been found wanting by 
Hufschmidt in 5 per cent. ; by Eulenberg in 4.20 per cent. ; by 
Berger in 1.56 per cent.; and by Feilkchenfeld in 1.3 per cent. 
(Deutsche Med. Wochen.y June 6, 1884), of eleven hundred and 
fifty cases examined by him. Dr. Gowers thinks that the appar- 
ent absence has been due to an imperfect examination; but Feilk- 
chenfeld^s investigations were made with the greatest care, and 
Mitchell and Lewis in one of their cases were also unable in any 
way to get the myotatic contraction. At present, therefore, we 
must consider that the knee-jerk may be absent in normal indi- 
viduals, although such absence is exceedingly rare. 

Diseases which lessen Knee-Jerh. — The knee-jerk is diminished 
by lesions that diminish or destroy functional activity in the per- 
ipheral nerves or their roots ; in the posterior region of the spinal 
cord, — i.e., in the neighborhood of the posterior nerve-roots ; in 
the ganglionic cells of the spinal cord, — i.e., the motor cells, — or 
in the muscle itself: consequently the knee-jerk is diminished or 
abolished in locomotor ataxia, or disease of the posterior columns of 
the spinal cord ; in diffused myelitis affecting the posterior regions 
or the central portions of the spinal cord ; in acute central myelitis 
affecting the gray matter of the cord ; in acute poliomyelitis 
(whether idiopathic in the child or due to metallic poisoning, as it 
usually is, in the adult), which causes destruction of the motor 
cells of the cord ; in diseases of the motor nerves, such as trauma- 
tisms, neuritis, tumors, etc., diphtheritic paralysis, which interfere 
with the conducting power of the motor or sensory nerves; in 
pseudo-muscular hypertrophy with destruction of the muscular 
tissue ; and probably also in fatty or granular degeneration of the 
muscles. In the first stages of some of the diseases which have 
been enumerated as destroying knee-jerk there is a condition of 



188 DIAGNOSTIC NEUROLOGY. 

excitation of the tissue which is finally to lose its power, and con- 
sequently a condition of exaggerated knee-jerk. This is notably 
the case in neuritis and myelitis. 

There are certain diseases which a priori might be expected to 
destroy the patellar-tendon reaction, but which do not do so. The 
most important of these is chronic poliomyelitis, or progressive 
muscular atrophy, as habitually seen in the adult. The explana- 
tion of the preservation of the knee-jerk in this aflFection is not, 
however, difficult. The individual cells of the ganglionic spinal 
groups are attacked one by one, and, although a muscle may have 
greatly wasted, those of its fibres which remain unaffected are 
still under the normal influence of spinal cells which have so far 
escaped the disease. In some cases of chronic poliomyelitis a 
condition of excitation precedes the destruction of the cells, as is 
especially revealed by the very pronounced fibrillary contractions 
of the wasting muscles. Under these circumstances the irritability 
of the muscle may be sufficient to give rise to exaggeration of the 
tendon-reactions. I have noticed, however, that in such cases the 
muscles are soon exhausted, so that when the patellar tendon is 
repeatedly tapped, the reaction, at first excessive, rapidly dimin- 
ishes in intensity, and at last fails to appear. 

How far the tendon-jerks are lost in acute diseases from the loss 
of muscle-tone which is part of the general degradation, is un- 
certain. Repeated studies of the condition of the knee-jerk in 
various chronic disorders not usually attributed to diseases of 
the nervous system are at present wanting. It would appear 
probable that when muscular relaxation exists the tendon-reac- 
tion would be feeble, but Dr. A. Money [Lancet, vol. cclxxxv. 
p. 842) finds that in all cases of marked typhoid fever, and also 
of phthisis, the knee-jerk is much exaggerated ; and in two cases 
of rheumatic fever a similar condition existed. In all these dis- 
eases the superficial or cutaneous or true reflexes were also grossly 
exaggerated. It is affirmed that habitually in diabetes the tendon- 
reaction is lost; but I have seen it exaggerated in that disease. 
Withdrawal of the inhibitory influence of the brain from the 
spinal cord is followed by increase of the knee-jerk, and a priori 
it is therefore probable that the knee-jerk may be diminished by 
rare lesions of the brain of such character and situation as to , 
augment its inhibitory reflex functions. I know, however, of no 



REFLEXES. 189 

clinical proof that stimulation of the motor cortex of the brain 
is capable of lowering the knee-jerk^ unless it be the fact that in a 
large proportion of cases of general paralysis of the insane (twenty- 
three out of sixty-five cases: Dr. W. Crump Beatley, Brain, 
April, 1885) it is diminished or abolished. The close connection 
between locomotor ataxia and general paralysis leads to the sus- 
picion that the loss of knee-jerk is due to posterior spinal sclerosis, 
a view which is confirmed by Dr. Beatley^s report of three cases, 
in which absence of the knee-jerk during life, without other dis- 
turbing evidences of implication of the spinal cord, was found 
after death to have been dependent upon sclerosis of the posterior 
columns of the cord. Further, in my own experience, cases of 
general paralysis with loss of the knee-jerk have habitually suf- 
fered from severe pains in the legs, evidently ataxic in character. 
Again, Dr. Beatley found in two cases of general paralysis in 
which exaggerated knee-jerk had existed during life pronounced 
lateral sclerosis of the cord. It appears that in general paralysis 
there is a very decided tendency to spinal sclerosis, and that the 
knee-jerk may be absent, exaggerated, or normal, according to 
the region of the spinal cord which is attacked by the secondary 
sclerosis. 

In diphtheritic paralysis the knee-jerk is diminished or lost, 
and, as was pointed out by Bernhardt, this loss may precede the 
paralysis of the palate. It is therefore important in all cases of 
diphtheria to examine the condition of the knee-jerk during the 
stage of convalescence. In some cases severe diphtheritic paraly- 
sis follows attacks which have originally been so light that their 
true nature has been overlooked. Under these circumstances the 
early loss of the knee-jerk is of great diagnostic importance. 

In the early stages of pseudo-hypertrophic paralysis the knee- 
jerk is present, but as the degeneration progresses it becomes 
less and less, and finally disappears entirely. Occasionally there 
is some difiBculty in diagnosing between a pseudo-hypertrophic 
paralysis and a very mild spastic palsy of childhood. In the 
latter disease, however, the tendon-reactions are exaggerated. 

It is commonly stated that the knee-jerk is lost in hysterical 
paraplegia. Dr. W. R. Gowers affirms that this is always an 
error of observation, due to the inability of the patients to relax 
the muscle of the thigh. 



190 DIAGNOSTIC NEUROLOGY. 

Of all the diseases in which the knee-jerk may be wanting, it 
is especially in locomotor ataxia that its absence has diagnostic 
importance. According to Albrecht Erlenmeyer {Alienist and 
Neurologist, vol. v. p. 455), the loss of the patella-reflex depends 
upon the sclerosis being localized in the extreme outer portion or 
external fibres (bandelottes externes) of the posterior columns. 

In any case of chronic nerve-failure without obvious symptoms 
or obvious causation, if the knee-jerk be absent there is a proba- 
bility that the patient is suflFering from posterior spinal sclerosis, 
and if there be conjoined any other symptom of the disease, the 
diagnosis may be considered as practically certain. Pain is next 
to loss of knee-jerk in its constancy and diagnostic importance 
in locomotor ataxia. When unaccountable neuralgic pains occur 
either singly or in paroxysms in the legs, or pain-crises are pres- 
ent (see chapter on Pain), the condition of the knee-jerk should 
always be carefully examined. It is remarkable how long poste- 
rior sclerosis may exist without producing any loss of co-ordina- 
tion. A patient of my own, who, until within a few weeks of 
his death from an intercurrent affection, was an active sports- 
man, had suffered for fifteen years from almost monthly attacks 
of furious neuralgic pain in the legs, which had been supposed 
to be of a rheumatic nature, but which I diagnosed to be due to 
locomotor ataxia, because the knee-jerk was lost, and because 
there was no pain on motion, nor soreness of the legs during the 
paroxysms of suffering. After death pronounced posterior spinal 
sclerosis was found. The question whether the presence of the 
knee-jerk proves that the patient has not posterior sclerosis is a 
very important one. Of all the symptoms of the disease, loss of 
the knee-jerk is the earliest and most constant, and I should be 
loath to make a positive diagnosis in any case in which it was 
preserved. A coexisting lateral sclerosis of the lateral columns 
might in some measure overcome the depressing effect of a poste- 
rior sclerosis. Usually, however, the loss masks entirely the con- 
dition of exaggerated excitability ; but in some cases the diagnosis 
may become a matter of difficulty when posterior sclerosis and 
lateral sclerosis coexist. There must be a stage in commencing 
posterior sclerosis in which the knee-jerk is only slightly dimin- 
ished, and it is possible that under such circumstances other 
symptoms of ataxia may be present in sufficient force to create at 



REFLEXES. 191 

le^st a suspicion of the true nature of the affection. Dr. Gowers 
states that he has in the early stage of true tabes seen the knee- 
jerk present on one side^ and has watched its gradual loss^ and in 
one case its gradual return. He further calls attention to the 
fact that in some rare cases when, as he believes, the true knee- 
jerk was lost, tapping on the patellar tendon caused a contrac- 
tion in the extensors of the knee very like that of the true knee- 
jerk, but which he believes was a true reflex, and not a myotatic 
contraction, because — 

First On many attempts to obtain the jerk, attempts made 
under the most satisfactory conditions, no movement could be 
obtained. 

Secondly, The contraction excited was oftener in the flexors 
of the knee than in the extensors, and frequently it was in the 
muscles of the opposite leg. 

Thirdly. Exactly similar contractions could be produced by a 
sudden prick of the skin over the tendon of the head of the tibia. 

It is not very uncommon for a cutaneous reflex action to persist 
in early tabes when the myotatic irritability is entirely lost. It is 
especially in such cases that difficulty of diagnosis arises : thus, 
the distinction between the local and the reflex contractions is not 
a matter of mere theoretical interest. In advanced stages of poste- 
rior sclerosis, not only are the superficial or skin reflexes abolished, 
but, if the lesions spread sufficiently high up on the cord, the deep 
true reflexes may be affected: thus, the power of gargling may be 
lost. In studying any such case, however, it must be remembered 
that there are some people who never can gargle. 

Diseases which inci^ease Knee- Jerk. — The knee-jerk is increased 
by brain-lesions which cut off* the influence of the cerebral hemi- 
spheres from the spinal cord : consequently in most cases of 
hemiplegia it is increased. In some cases this increase does 
not appear until eight or ten days after the accident; but 
usually, if the hemiplegia be at all complete, there is a notable 
exaggeration in the course of two or three days. Sometimes 
directly after the apoplexy the knee-jerk is diminished or abol- 
ished on the paralyzed side. This is probably due to the propa- 
gation of the irritation of the fibres of the brain below the lesion 
downward to the cerebral inhibitory centres. The increase of the 
knee-jerk is often pronounced in cases of hemiplegia in which 



192 DIAGNOSTIC NEUROLOGY. 

there is no distinct rigidity ; but when either an early or a late 
rigidity manifests itself, the activity of the myotatic contrac- 
tion is excessive. Section or lesion of the pyramidal tract in the 
spinal cord is even more decided in its effect upon the knee- 
jerk than is a similar organic change situated higher up : hence all 
affections which interrupt or break the integrity of the spinal cord 
are accompanied with exaggeration of the tendon-reaction. The 
most important of these affections are traumatism of the cord, 
transverse myelitis, and spinal tumors. Again, any lesion which 
excites, without destroying, the motor ganglionic cells of the cord, 
increases the knee-jerk : hence its excessive activity in various 
forms of subacute myelitis. In acute myelitis the lesion pro- 
gresses so rapidly that the reflexes, at first exaggerated, may be 
diminished or lost in the course of a few hours or days. In 
chronic myelitis the knee-jerk is diminished or increased accord- 
ing to the seat and character of the lesion, — i.e., as the organic 
alteration excites or paralyzes the intra-spinal mechanism connected 
with the patellar reaction. 

Of all chronic affections the one which is especially associated 
with exaggeration of the various myotatic reactions is sclerosis of 
the lateral columns. In marked cases of this affection not only 
will the slightest tap upon the patellar tendon produce violent 
contractions of the quadriceps femoris, but even a blow upon the 
tibia, or upon the patella itself, will suffice. Not rarely a single 
blow will produce three or four or even more successive contrac- 
tions, and in some cases it is possible to induce a knee-clonus. 

Hysterical contractures may be confounded with lateral sclerosis ; 
but the myotatic contractions are usually not so pronounced in 
hysteria as in the organic disease : nevertheless, they may be just 
as decided. In a case now under my care, which I believe to be 
chronic multiple neuritis, the knee-jerk is as active as in a case of 
lateral sclerosis. 

Effect of Disease on Ankle- Clonus. — Ankle-clonus occurs only 
when the myotatic reactions are exceedingly exaggerated. Its 
most common cause is lateral sclerosis; but it may be due to hys- 
teria or to subacute myelitis. 

JEffed of Epilepsy. — According to the observations of Westphal 
and of Gowers, none of the myotatic contractions can be obtained 
immediately after a very severe epileptic fit, but at the end of 



REFLEXES. 193 

about half a minute the knee-jerk can again be induced^ and fre- 
quently it becomes excessive, and during the first few minutes 
after the fit ankle-clonus may be present. In those cases in which 
the epileptic fit is unilateral and due to an organic brain-disease, 
the myotatic contractions are, immediately after the convulsion, 
usually exaggerated upon the side of the convulsion. Occasionally 
the myotatic contraction which has been produced in the affected 
muscle artificially becomes the starting-point of a general seizure. 
After slight attacks of epilepsy the myotatic contractions often 
remain as normal, and after moderately severe fits there may be 
immediately increased knee-jerk and ankle-clonus. The true re- 
flexes are usually abolished for a few moments after a severe 
epileptic fit. 

Effect of Hysteria on Myotatic Contractions. — In hysterical con- 
vulsions the myotatic contractions are sometimes normal, but are 
usually in severe cases increased. According to Dr. Paul Richer, 
in hysterical catalepsy they are abolished. 

The increase of the myotatic contractions in the major hysteria 
is shown by the excessive effect of a slight irritation upon the 
muscle directly implicated, and by the tendency to propagation of 
the myotatic contractions. Further, the character of the myotatic 
contractions is not rarely altered : they are prolonged, almost 
tetanic, and after a severe blow may amount to a more or less per- 
manent contracture. According to Richer, the propagation of the 
myotatic contractions frequently occurs from the leg to the arm, but 
never in an inverse method, so that a single blow upon the patellar 
tendon may give rise to muscular contractions involving the whole 
of one side of the body, whereas a blow upon an arm-tendon affects 
only the muscles of the neighborhood. When this abnormal 
neuro-muscular excitability is very pronounced, a slight blow, or 
even a mere pressure upon the muscle itself, will produce contrac- 
tions. The effect of striking a bone may be very marked. 



13 



CHAPTER IV. 

DISTURBANCES OF EQUILIBRATION. 

Under the head of disturbances of equilibration I propose to 
consider three more or less allied, but at the same time quite 
distinct, symptoms : first, disturbance of co-ordination ; second, 
cerebellar titubation ; third, vertigo. 

DISTURBANCE OF CO-ORDINATION. 

It does not seem to me necessary to discuss here in detail the 
physiology of co-ordination. For the purposes of the clinician it 
suffices to define it as that function by which the muscles are so 
controlled in their movements and relaxations as to execute com- 
plicated acts under the impulse of the will. Without the power 
of co-ordination equilibration cannot exist, but co-ordination may 
be perfect and yet equilibration be deranged. When the power 
of co-ordination is lost for the legs, equilibration is affected, be- 
cause it is impossible for the individual to control the move- 
ments of those muscles upon which he depends for his upright 
position and for the power of w^alking. If, however, the function 
of co-ordination be lost in the arms alone, the gait remains perfect, 
although it is no longer possible for the individual to execute 
delicate movements with the hands. 

Loss of co-ordination is usually first manifested in the legs, 
because in the majority of cases centric disease begins in the 
lower portion of the spinal cord, and naturally affects the lower 
extremities ; but when a sclerosis commences in the upper por- 
tions of the cord the arms may be the first to suffer. Under 
these circumstances the patient notices that he is losing the power 
of doing finer actions with the hands, although the grip and the 
general strength of the arm may be un weakened. Difficulty is 
perceived in buttoning and unbuttoning clothes, in picking up 
pins, threading needles, etc. When the fingers are from any 
cause anaesthetic, it is difficult for the patient to do many of 
194 



DISTURBANCES OF EQUILIBRATION. 195 

these smaller acts, and care is sometimes necessary not to mistake 
the character of such disablement. A rough test of the power of 
co-ordination in the general movements of the arm is made by- 
causing the patient to extend the arm at full length, with the hand 
closed, except the forefinger, and then to bring this rapidly to the 
point of the nose. 

When the power of co-ordination is entirely lost in the legs the 
patient is unable to stand or walk, even with the aid of crutches. 
When lying in bed, however, he can kick in every direction, and 
can execute all movements of the leg with great force. Before 
this condition of complete disablement is reached there is usually 
a stage in which the patient is able to walk by means of crutches. 
Under these circumstances the peculiar erratic method in which 
the legs are thrown in stepping, the way in which they seem to 
thrust themselves about, independently of the will of the pa- 
tient, is characteristic of disordered co-ordination. Preceding the 
crutch period there is generally a prolonged stage during which 
the ataxia manifests itself in a peculiar gait. At this time, hold- 
ing the hand of a second person, or using a cane, is of great 
assistance in walking. The feet are kept widely apart and strad- 
dling, and it is impossible for the patient to walk, or even to 
stand, with his eyes shut. Very frequently the subject will him- 
self notice that his difiiculty of walking is greatly increased at 
night. 

When the loss of co-ordination is very slight, some little care 
and examination are necessary to detect it. Under these circum- 
stances it will be found that the patient, when his eyes are shut, 
sways more than he ought to during standing, and also walks 
with some difficulty. In the very slightest perceptible loss of co- 
ordinating power the only discoverable derangement may be an in- 
ability to stand upon one foot with the eyes closed. In its incip- 
iency the sclerosis of locomotor ataxia is often more pronounced 
in one side of the spinal cord than in the other : hence a patient 
may be able to co-ordinate sufficiently to stand firmly upon the one 
foot, even with the eyes closed, and yet be unable to maintain his 
position upon the other foot. In a doubtful case the patient 
should be required to walk backward and to attempt to turn sud- 
denly. Any marked awkwardness in these actions should give 
rise to suspicion. It is necessary, however, not to confound the 



196 DIAGNOSTIC NEUROLOGY. 

awkwardness arising from muscular weakness, or especially from 
muscular stiffness due to incipient spasmodic tabes, with that pro- 
duced by a slight loss of co-ordinating power. Again, in certain 
cases of cerebral disease with vertigo the patient will execute these 
movements with difficulty and awkwardness, although the true 
co-ordinating power is not affected. In some of my patients the 
first perception of disablement has been in walking through 
woods or over rough, uneven ground. 

Causes of Loss of Co-ordination. 

Loss of co-ordination without loss of actual motor power is 
in the great majority of cases due to sclerosis of the posterior 
root-zones of the spinal cord, — ix,, locomotor ataxia. It may, 
however, be a very early or even a prodromic symptom of general 
paralysis of the insane, and may occur in multiple neuritis. 

Locomotor Ataxia. — Loss of co-ordination in the legs without 
loss of power is so characteristic of locomotor ataxia that the gait 
it causes is commonly known as the ataxic gait. When a posterior 
sclerosis is sufficiently advanced to affect progression, but has not 
yet reached the stage in which a stick or other support is necessary, 
the patient walks with his head a little bent forward and the eyes 
directed to the ground. The trunk inclines upon the thighs, 
whilst the feet are held in advance of the buttocks, with the legs 
widely separated from. each other. At the same time, owing to 
the excessive contractions of all the muscles of the lower extrem- 
ities, the leg proper is extended somewhat rigidly upon the thigh, 
and there is very little movement at the knee-joint. The ad- 
vancing leg is therefore raised from the ground in some degree by 
an elevation of the pelvis, although at the same time some flexion 
does occur at the knee-joint. By these conjoint movements the 
foot is freed from the ground, and, having been flung forward and 
outward by a rapid muscular jerk, comes down with a thump like 
a solid mass. In some cases the heel is the last to leave the ground 
and the first to touch it. Not rarely the pelvis is so much in- 
clined during walking as to carry the centre of gravity too far to- 
wards the side of the stationary leg. To counteract this and main- 
tain the balance of the body, the upper portion of the trunk is 
curved towards the advancing leg by a contraction of the erector- 



DISTUKBANCES OF EQUILIBRATION. 197 

spinse muscles, or the arm corresponding to the advancing leg is 
thrust out laterally. The alternation of these movements at each 
step may give a pendulum-like swing to the body. In a more 
advanced stage of locomotor ataxia the patient is able to walk 
only by the help of two sticks or crutches. The body is thrown 
forward, in order to counteract the tendency to fall backward 
produced by the peculiar position assumed by the legs, which are 
held in advance of the buttock on account of the tendency to 
undue contraction of their extensor muscles ; the foot is usually 
at an obtuse angle to the leg, and the thigh at an obtuse angle to 
the trunk. If under these circumstances the trunk be erect, the 
line of the centre of gravity would fall through the buttocks pos- 
terior to the point of support, — i.e., the foot, — and consequently 
the patient would fall backward. To overcome this, the trunk is 
often bent so far forward that the line of the centre of gravity is 
in front of the feet, and the patient would fall forward if he were 
not supported by a stick or crutches. All the movements executed 
with the legs are performed with great stiffness and by sudden jerks. 
The straddle is usually very marked, and the leg is raised from 
the ground by an elevation of the pelvis in the method already 
described. Still later in the disorder the legs are entirely beyond 
the control of the patient. They are thrown about in wild, irreg- 
ular, choreiform movements, which render them of no use what- 
ever in walking. Under these circumstances progression is impos- 
sible. AYhen the lesion travels up the spinal cord all power of 
co-ordinating the muscles of the trunk may be lost, so that the 
patient is no longer able to sit in a chair. 

General Paralysis. — In general paralysis of the insane, the 
early loss of co-ordination is felt almost exclusively in the 
hands, and is shown chiefly in delicate skill-requiring acts, such 
as writing, engraving, etc., whilst in locomotor ataxia it is ex- 
tremely rare for the arms to be first attacked. The other symp- 
toms of the two diseases are in no way similar : locomotor ataxia 
is, however, a very common complication of general paralysis. 
(See General Paralysis.) 

Multiple Neuritis. — Multiple neuritis affecting the sensory 
nerves is always accompanied not only with pain, but also with 
pronounced tenderness over the nerve-trunks, which at once dis- 
tinguishes it from locomotor ataxia. There is, however, evidence 



198 DIAGNOSTIC NEUROLOGY. 

that a multiple neuritis is often incited by, or at least follows 
upon, chronic posterior sclerosis. 

Loss of Co-ordination as a Complicating Symptom. — In 
multiple sclerosis, and in certain forms of chronic myelitis, the 
posterior column shares the lesion along with other portions of 
the cord. Under these circumstances the loss of co-ordination is 
associated with various symptoms, such as palsy, spasm, etc., due 
to other portions of the cord being affected, and, indeed, may be 
so entirely masked by these symptoms that its presence cannot be 
detected. 

TITUBATION. 

Cerebellar Affections. — If a lesion be confined to one hemi- 
sphere of the cerebellum it may produce no symptoms whatever, 
and in any case cannot be diagnosed with certainty. Vomiting, 
with occipital headache and general failure of health, might in 
some of these cases lead to a suspicion of the seat of the dis- 
order, but these symptoms may be entirely wanting, as is shown 
by a case reported by Dr. Loomis {Amer. Med, Times, 1862, iv. 
124), in which the symptoms simply resembled those of a low 
fever, although a cerebellar tumor the size of a small orange 
was found after death. When, however, a growth or other lesion 
of one hemisphere of the cerebellum causes such enlargement as 
to exert pressure upon neighboring parts, various paralyses result. 
The encroachment upon the medulla may lead to an imperfect 
hemiplegia or even to general motor failure, or hypoglossal, facial, 
or other local paralyses may result from the pressure exerted by 
the enlarged hemisphere upon nerve-trunks. If the trigeminus 
nerve be involved, a true anaesthesia dolorosa may be produced : 
loss of the power of swallowing may also be a prominent symp- 
tom. On account of the proximity of the corpora quadrigemina, 
blindness from pressure is a not infrequent result of cerebellar 
tumors. When the cerebellar lesion occupies the middle lobe it 
causes peculiar disturbances of motion, which are pathognomonic, 
and to which the name of cerebellar titubation has been given. 
Very frequently cerebellar titubation is associated with giddiness, 
but, as in some instances giddiness is absent, the disorderly 
movements are plainly not caused by the vertigo. 

Gait in Cerebellar Disease. — The position which is assumed by 



DISTURBAKCES OF EQUILIBRATION. 199 

the victim of cerebellar titubation during standing resembles that 
of locomotor ataxia. The feet are held well forward and widely 
separated from each other. If the attempt is made to bring 
them close together, peculiar movements of extension and flexion 
occur in the feet, and at the same time the trunk begins to rock 
and stagger more and more violently, until, in extreme cases, the 
subject falls unless he can seize some support. In unusual in- 
stances the movements are definite and in one direction ; but 
commonly they are irregular, and vary both in direction and 
in force. The staggering may be so great that the patient is 
unable to move a step. Very commonly it is impossible for him 
to turn suddenly without falling. Sometimes the symptoms are 
intensified by darkness or by closing the eyes, whilst in other 
cases they are not thus affected. The walk resembles that of an 
intoxicated man. There is a similar staggering, with to-and-fro 
movements of the whole body, resulting in a zigzag instead of 
a straightforward progression. In most cases the feet are raised 
only a short distance from the ground, and are moved with a 
peculiar irregularity of step. In some instances the patient has 
a tendency to fall or run backward, or this may be reversed and 
the patient continually falls or runs forward. This is, however, 
by no means a constant phenomenon, nor is it when present abso- 
lutely characteristic of cerebellar tumor. At least I have seen 
cases in which a similar symptom existed when there was no other 
reason to suppose a cerebellar tumor : in no instance, however, 
have I been able to confirm the diagnosis by an autopsy. The 
movements in titubation are sufficiently distinct from those of 
ataxia to make their recognition in most cases easy. A further 
difference is to be found in the fact that whilst in cerebellar dis- 
ease the patient lying in bed is able to move his legs with normal 
promptness and accuracy, in spinal disease the movements in bed 
are almost as disorderly as during walking. Further, whilst 
ataxia often affects the arms, titubation is confined to the lower 
extremities. It is, indeed, due to disorder of equilibration, and 
not to any loss of muscular control, and appears only when the 
attempt is made to exercise the function of equilibration. 

Diagnostic Value of Titubation, — Titubation is probably pa- 
thognomonic of disease of the cerebellum, and, as Nothnagel 
has shown, of the middle lobe of the cerebellum. There have, 



200 DIAGNOSTIC NEUROLOGY. 

however^ been cases in which the middle lobe of the cerebellum 
has been involved without the production of titubation. The 
explanation of Nothnagel, that this has been because suflBcient 
of the middle lobe to perform its function has escaped in- 
jury, may be accepted, at present, as at least the best that can 
be given. 

Rotatory Movements. — Titubation must not be confounded with 
the rotatory movements which occur when the cerebellar pedun- 
cles are implicated, either as they enter the pons or higher up. 
These rotatory movements, the '' movements of manege," are 
around the long axis of the body. Prof. Rosenthal sums the 
diagnostic points of tumors of the cerebellar 'peduncles as headache, 
vertigo, disorders of the special senses, hemiplegia, unsteady gait, 
with a tendency to fall upon the side, and partial rotation around 
the vertical axis, with lateral rotation of the head. There have, 
however, been recorded a number of cases of lesions of the cere- 
bellar peduncles without rotatory movements, and it is probable 
that such movements, when present, are produced in some indirect 
manner. 

VERTIGO. 

Vertigo may be defined to be a sensation of moving, or an ap- 
pearance of motion in surrounding objects which are really at rest. 
It is a sense of defective equilibrium without actual disturbance 
of position, and varies in intensity from the slightest giddiness to 
that condition in which everything about the victim seems to be 
involved in a whirling chaos of motion. In the slighter forms 
of the symptoms, those to which the term giddiness is well ap- 
plied, there is a feeling as though the head itself or its contents 
were in motion: hence the popular term ^^ swimming in the head.'' 
Closely allied to this mild vertigo is the sensation of rising through 
the air, which almost every one has experienced after fatigue when 
lying in bed. An abnormal sensation somewhat similar to this, 
but more distressing and terrifying, is that of falling through the 
air, which in extreme cases is accompanied by a feeling as though 
the earth were opening and rising up to swallow its victim. In 
vertigo proper the movement is in the surrounding objects : the 
furniture and other contents of an apartment appear to revolve 
more or less rapidly, to dance backward or forward, or to reel 



DISTURBANCES OF EQUILIBRATION. 201 

with an irregular, staggering gait. The ground rises, or sinks, or 
rises and sinks like the waves of the ocean. Houses move, hills, 
trees, and rocks slant hither and thither, and in some instances 
the whole landscape inverts itself and hangs above the head, 
threatening ruin. 

In vertigo relief is generally afforded by assuming a horizontal 
position, or even by the closure of the eyes, but in severe cases these 
measures fail, and the patient lies in bed clutching at any available 
support, in constant fear of falling. In many cases along with 
the vertigo there are distinct perversions of special senses. Mist- 
iness of vision, enlargement or lessening in the size of objects, 
tinnitus aurium, the rush of water, intermittent pulsations, the 
clanking of pumps, the hissing of teakettles, — these and many 
other extraordinary alterations of perception, or even absolutely 
subjective sights and sounds, may form a part of the vertiginous 
paroxysm. In the majority of such cases, however, disturbance 
of the special senses is the origin of the vertigo, or the subjective 
sensations and the vertigo depend upon a common cause. 

Vertigo may be present almost all the time, or at least be pro- 
duced by every change of position, or even by the erect posture, or it 
may come on at irregular intervals and be of a purely paroxysmal 
type. To the condition in which paroxysms of vertigo succeed one 
another in rapid succession the name of the vertiginous status has 
been given by Dr. S. Weir Mitchell, — a name which was evidently 
suggested by the parallel between this condition and the epileptic 
status. When the type of the disorder is strictly paroxysmal the 
j attacks are often very severe, and are accompanied by nausea and 
I vomiting, and even by relaxation of the bowels and the rapid 
secretion of a limpid urine, like that of the hysterical fit. The 
\ gastro-intestinal disturbance in a large proportion of these cases 
! is secondary to the vertigo, but, as will be discussed in detail later, 
I the vertigo may be dependent upon the gastro-intestinal irritation. 
In severe vertigo there is frequently some mental confusion, which 
may end in complete loss of consciousness. When this happens, 
the vertigo is probably due to hysteria, epilepsy, organic brain- 
disease, or uraemia. As insisted upon by Dr. Mitchell, a distinct 
aura sometimes precedes the vertiginous paroxysm, or in some 
I cases there is an abrupt onset with the sensation of a snap in the 
i head; more rarely the vertigo is ushered in by a sensory dis- 



202 DIAGNOSTIC NEUROLOGY. 

charge, such as the perception of light or sound. In such cases 
there is reason to fear that the vertiginous attack is allied to epi- 
lepsy. 

Nature of Vertigo. — The theory that vertigo is produced by 
disturbance of the circulation of the brain has met with wide- 
spread acceptance, but I do not think it can be received as a gen- 
eral theory applicable to all cases. I am not prepared to enter 
into a discussion of the theory of vertigo, but it seems to me 
probable that at least two, and perhaps more, distinct conditions 
are habitually united under the one name, because the sensations 
which accompany them are similar. The vertigo of epilepsy, the 
vertigo of organic brain-disease, and the so-called laryngeal vertigo 
are probably caused by nervous discharges allied to those which \ 
provoke epileptiform convulsions, whilst the gastric vertigo and ■ 
many toxsemic vertigoes are of different character. The epilepti- 
form vertiginous attack is often preceded by an aura, and naturally 
ends in unconsciousness, whilst the typical gastric vertiginous 
paroxysm has no aura, and terminates in vomiting. 

Causes of Vertigo, — The diseases upon which vertigo may de- 
pend, or of which it is a symptom, can best be studied under 
eight headings : 

1. Organic Vertigo, in which the symptom is dependent upon 
some demonstrable structural alterations of the brain or spinal 
cord. 

2. Cardiac Vertigo, in which the vertigo depends upon some 
evident alteration of the circulation. 

3. Epileptic Vertigo, in which the attack replaces a paroxysm 
of idiopathic epilepsy. 

4. Hysterical Vertigo, in which the symptoms are hysterical: 
in this division I shall include those cases in which the vertigo is 
the result of nervous exhaustion. 

5. Peripheral Vertigo, in which the paroxysm depends upon an 
irritation of some peripheral nerve-filaments. 

6. Vertigo of the Special Senses, which is caused by some de- 
rangement of the special senses. 

7. Toxsemic Vertigo, in which the symptoms are toxaemic, due 
to a mineral or a vegetable principle, or to a disease-poison in the 
blood. 

8. Cases in which at present no explanation of the vertigo 



DISTURBANCES OF EQUILIBRATION. 203 

is forthcoming, and for which the name of Essential Vertigo has 
been proposed by J. Spence Ramskill. 

Organic Vertig-o. — Chronic meningitis, brain-abscesses, spe- 
cific, cancerous, or simple tumors, atheroma of the basal arteries, 
and almost any chronic brain-disease producing or accompanied 
by coarse structural alterations, may be the cause of vertiginous 
attacks. Yertigo is apt to be especially severe when the focal dis- 
ease is situated in the cerebellum, but cerebellar atrophy, and even 
cerebellar tumors, may exist without pronounced giddiness, and a 
tumor may be located in any portion of the brain, even in the ex- 
treme frontal lobes, and yet cause giddiness. Organic vertigo is 
in the majority of cases not severe, although it has a distinct ten- 
dency to end in unconsciousness. I cannot remember a case in 
which the cerebral hemispheres were alone implicated in which 
the sense of movement either of the person himself or of sur- 
rounding objects was very violent. The recognition of the cause 
of the vertigo in cases of structural brain-disease is to be based 
upon the other symptoms of the case. 

In general paralysis of the insane vertiginous attacks are not 
rare. They must be looked upon as an abortive form of the epi- 
leptic convulsions which are common to these disorders. 

According to Charcot, vertigo marks the invasion of multiple 
cerebral sclerosis in about three-fourths of the cases. I have 
seen a large number of cases of this disease, and vertiginous 
attacks have certainly been the exception. Charcot says that the 
vertigo is usually gyratory ; all objects are apparently whirling 
round with great rapidity, and the individual himself feels as 
though revolving on his axis. Charcot further states {Diseases of 
the Nervous System, Phila., 1879, p. 160) that "the vertigo in 
question is all the more interesting because it belongs neither to 
locomotor ataxia nor to paralysis agitans, and may consequently 
help in forming a diagnosis.^^ Notwithstanding this statement, 
vertigo is a not very rare symptom in locomotor ataxia. This 
seems to be true not only of cases like those reported by Fournier 
{De VAtaxie locomotrice, p. 251), in which the disease is really 
not locomotor ataxia but cerebro-spinal syphilis, but also of genuine 
posterior spinal sclerosis. In the last-named aflFection the giddi- 
ness occurs especially in those cases which have marked ocular or 
aural disturbance or severe gastric crises. It is very probable 



204 DIAGNOSTIC NEUROLOGY. 

that in such instances the vertigo is a secondary and not a primary 
symptom of the disorder^ — ix., is caused by the peripheral irri- 
tation or the sensory disturbance. Dr. S. Weir Mitchell, however, 
affirms that vertigo may occur in locomotor ataxia independently 
of ocular disturbance, and T. Grainger Stewart (On Giddiness, 
Edinburgh, 1884) insists that the vertigo may be due to the 
centric lesions. 

Epileptic Vertigo. — Attacks of giddiness of the mildest pos- 
sible type to be noticeable may be a symptom, or rather a parox- 
ysm, of a hopeless idiopathic epilepsy. Frequently the nature 
of such a paroxysm is mistaken. The epileptic vertigo may be 
scarcely perceptible, or it may be severe and end in disturbance 
of consciousness. There is nothing in the vertigo itself upon 
which the diagnosis of its nature can be made. The judg- 
ment must be based upon concomitant circumstances, such as 
known hereditary tendency to epilepsy, absence of the ordinary 
known causes of vertigo, age of the patient at which the vertigo 
appeared, etc. A previous history of convulsions during child- 
hood, with persistence of the vertiginous paroxysms, would be 
decisive. If in any case recurrent vertigo be ushered in by an 
aura, and be followed by mental disorder, a sense of transporta- 
tion through space, a marked subjective sensation, such as that 
of a bright light, or of a loud sound, suspicion should be 
strongly roused unless the subject be hysterical. When any dis- 
turbance of consciousness, muscular rigidity, or clonic convulsive 
movements accompany the vertigo, the prognosis becomes grave. 
Such vertigo, if not hysterical, is almost invariably organic or 
epileptic. The occurrence sooner or later of a pronounced epileptic 
paroxysm will generally settle the diagnosis. Dr. George Parker 
{Brain, vii. 525) affirms that in epileptic vertigo there is '^always 
falling towards one side, never, as in brain-disease, a sense of 
spinning round, nor, as in eccentric vertigo, of the room moving.'^ 
The correctness of this statement seems to me extremely doubtful. 

Cardiac Vertigo. — Vertigo is a not rare symptom of chronic 
cardiac disease, especially of fatty degeneration, or other diseases of 
the heart, accompanied by failing power. In some of these cases 
abrupt alterations of position, especially sudden rising from the 
bed, or prolonged stooping, may produce a vertiginous paroxysm. 
Even in the normal individual it is not rare for rapid forced 



DISTUEBAXCES OF EQUILIBRATION. 205 

breathing, prolonged standing with the head downward, violent 
straining at stool, excessive vomiting, or other acts which cause 
marked disturbance of the circulation, to provoke giddiness. In 
cases of doubtful organic brain-disease I have sometimes been 
aided in making the diagnosis by the ease with which excessive 
giddiness was produced by acts like those just spoken of. The 
giddiness which forms a prominent symptom of the mal de mon- 
tagne, an affection caused in some persons by the rarefied air of 
high mountains, and manifested by headache, vertigo, and dysp- 
noea, with sometimes nausea and vomiting, is probably due to 
disturbance of the circulation. The giddiness of anaemia and that 
of plethora with excessive cardiac action probably have similar 
explanation. Sudden loss of the cerebro-spinal fluid, — abrupt 
changes of atmospheric pressure, such as is experienced in going 
from a chamber containing compressed air into the ordinary 
atmosphere, — these and other conditions or acts not necessary here 
to detail may cause giddiness by disturbing the brain-circulation. 

Giddiness is very common in anaemia. Indeed, it may be said 
to be a constant symptom, if only the anaemia be sufficiently 
pronounced. Severe vertigo is, however, rarely, if indeed ever, 
caused by anaemia, since in extreme cases the giddiness soon 
merges into syncope. Anaemic giddiness is prone to be especially 
developed by changes of posture which suddenly affect the blood- 
supply, such, for instance, as abruptly rising from the horizontal 
to the erect posture. After protracted illness, during the feeble- 
ness of convalescence the first attempts at getting up are apt to 
cause swimming in the head. 

The vertigo which occasionally develops in persons of advanced 
age may be considered as an organic vertigo, or as one due to dis- 
turbance of the circulation, for it probably depends upon a lack 
of blood-supply to the brain-cells, the result of the atheromatous 
degeneration of the vessels. When once developed it is apt to 
be a persistent, obstinate symptom. A vertigo of similar char- 
acter may be caused by syphilitic or gouty changes in the cere- 
bral vessels, and occasionally precedes brain-softening. 

Hysterical and Neurasthenic Vertig-o. — Vertiginous sensa- 
tions are not a prominent symptom of hysteria, and when present 
are apt to take some unusual form. Almost any variety of ver- 
tigo may, however, be so closely counterfeited by the hysterical 



206 DIAGNOSTIC NEUROLOGY. 

disorder that great care will be necessary to avoid error in diag- 
nosis. This is especially true when tinnitus aurium or other 
sensory disturbance coexists with the vertigo and affords a picture 
of organic brain-disease. A diagnosis of such organic disease 
should be made with great reluctance whenever there is a pro- 
nounced hysterical temperament. 

In neurasthenia giddiness or swimming in the head is mod- 
erately common, though rarely, if ever, severe. It seems some- 
times to be connected with lack of proper blood-supply to the 
brain, and so far to be related to anaemic vertigo ; it is also based 
to a greater or less extent upon a morbid sensitiveness of the 
nerve-centres, and is provoked by peripheral irritations which in 
health make no impression. Hence bright lights, as the flashing 
of a mirror, loud sounds, bad smells, etc., may in a neurasthenic 
produce a giddiness which is in a sense ocular, aural, or nasal. 

Neurasthenic vertigo is often the result of long-continued 
overwork, of sexual excesses, or of prolonged lactation. Indeed, 
almost any persistent depressing cause may bring about the bodily 
condition which produces vertigo. It is evident that this form of 
vertigo is in many cases allied to anaemic vertigo, since nerve- 
exhaustion and poverty of blood not rarely coexist. 

Peripheral Vertigoes. — Vertigoes which are due to irritation 
of some peripheral nerve-filaments constitute a numerous and 
important class, in which are included laryngeal, gastric, and in- 
testinal vertigo. 

In 1876 {Gaz. Med, de Paris, 1876, p. 588), Prof. Charcot de- 
scribed, under the name of laryngeal vertigo, several cases of 
an affection that has since been repeatedly observed. The attack 
begins with a burning or itching in the larynx, that causes in a 
moment a violent access of spasmodic cough, which is soon fol- 
lowed by a brief vertigo, ending in complete loss of consciousness, 
lasting for a very few minutes, during which, in some of the cases, 
there have been convulsive movements of the face and even of 
the extremities. The paroxysm is not followed by nausea and 
vomiting, as is ordinary severe vertigo, nor yet by sleep, as is 
typical epilepsy.* 



^ See Dr. Gasquet, Practitioner ^ August, 1878 ; Dr. Sommerbrodt, Berlin- 
Klin. Wochenschrift^ September, 1876; Dr. Krishaber, Annales de VOreille 



DISTURBANCES OF EQUILIBRATION. 207 

Within certain limits the symptoms have varied considerably 
in the recorded cases. Usually the cough is severe, but in some 
instances it has been slight. The vertigo may be pronounced, 
but seems to have been in most cases very mild, and in some 
altogether wanting. Consciousness, often completely lost, may be 
imperfectly preserved, or may be even unaffected. The occurrence 
in the same case (that of Dr. Lefferts) of attacks varying from the 
slightest vertigo to complete unconciousness shows that a unity of 
character runs through the varying paroxysms. There has been 
considerable discussion as to whether these attacks should be called 
vertiginous or epileptic. But the question is probably one of words 
merely. There is probably no difference, except in intensity, be- 
tween some forms of vertigo and an epileptic attack. One con- 
stantly replaces the other in an idiopathic epilepsy. The probable 
explanation of laryngeal vertigo is that a reflex nervous discharge 
is caused by the laryngeal irritation. In some of the cases gross 
lar}T}geal lesions (polypus. Dr. Sommerbrodt) have been noted, 
in others redness of the laryngeal mucous membrane, in others 
no lesion. Asthma has in one case apparently caused the attack, 
the onset of which was felt in the trachea. {Le Progres 3Ied,, 
1879, p. 317.) When laryngeal disease has been found, its cure 
has been followed by relief; and even when no lesion has been 
apparent, cauterization of the larynx has done good. 

I think it is certain that vertiginous and epileptoid attacks may 
be produced by a peripheral laryngeal irritation ; but some care 
may be necessary not to mistake a true epilepsy commencing with 
a laryngeal aura. Laryngeal crises of locomotor ataxia also may 
simulate a laryngeal vertigo. It is probable that in some cases an 
attack of unconsciousness may, as insisted upon by Dr. Elsberg, 
be precipitated by a spasm of all the laryngeal abductor muscles, 
arresting respiration. 

Gastric vertigo occurs in an acute form as the result of an acute 
indigestion or gastric irritation. In some individuals the indul- 
gence in strawberries, lobsters, shell-fish, or other article of diet 
to most persons harmless, invariably produces a severe vertigo, 
undoubtedly by irritating the gastric nerves. Irritation of the 

et du Larynx J viii. ; Dr. George M. Lefferts, Trans. Amer. Laryngol. Soc, 
1883; Dr. Charcot, Le Progres Medical, April, 1879. 



208 DIAGNOSTIC JSTEUROLOGY. 

mucous membrane of the stomach not intense enough to cause a 
vertiginous paroxysm may produce great flushing of the face or an 
intense pain just below the ears. Acute indigestion with excessive 
acidity may provoke an intense reflex headache or a violent attack 
of vertigo^ the paroxysm in either case often being accompanied by 
partial blindness or double vision, and finally by nausea and vom- 
iting, followed by relief. Not rarely the headache and the vertigo 
are both present. 

Chronic gastric vertigo, due to persistent dyspepsia, is a much 
rarer affection than was supposed by Trousseau and his followers. 
In those cases of chronic dyspepsia in which the more or less 
constant vertigo is at its worst two to four hours before eating, 
it seems to me as rational to ascribe the vertigo to the presence in 
the blood of products of imperfect digestion as to attribute it to 
gastric irritation. In some dyspeptics, however, there are more 
or less frequent paroxysms of vertigo, with ocular disturbance 
and sick stomach, closely simulating those of an acute gastric 
vertigo. 

It is possible that the vertigo which occurs long after eating in 
chronic dyspepsia may sometimes be due to an intestinal irritation, 
as is undoubtedly the giddiness with a sense of weight over the 
brows, or even of burning in the eyes, which may be the only 
manifest symptom of tapeworm. 

Vertig^o from the Special Senses. — It is well known that cer- 
tain rapid changes of position produce giddiness, notably rapid 
whirling, as in the waltz, swinging, as in the play of children, 
and the rocking motion of the ocean. The peculiar sinking feel- 
ing which is experienced in the abdomen during the descent of the 
swing and during the going down of the ship into the trough of 
the sea indicates very strongly that the vertigo and the giddi- 
ness which accompany these movements are, at least in part, the 
result of afferent impulses which are produced in the abdominal 
viscera by the rapid assumption of positions to which they are 
unaccustomed. On the other hand, the relief which to some 
extent is secured in all these cases by closure of the eyes indi- 
cates that the rapid passage of objects in abnormal positions or 
abnormal succession before the eyes is at least one factor in the 
production of the vertiginous sensations. 

Ocular Vertigo. — Various ocular defects or diseases cause ver- j 



DISTURBANCES OF EQUILIBRATION. 209 

tigo. The most frequent of these is paralysis of the external 
rectus ; but any muscular palsy which causes a discord in the optic 
axis may produce vertigo. Under these circumstances closing the 
affected eye usually puts a stop to the giddiness. In most cases 
shutting the sound eye does not produce relief. The vertigo which 
in these cases is present when both eyes are open is probably the 
result of the confusion of the nerve-centres produced by the non- 
agreement of the eyes in their representation of objects. The 
giddiness which exists after closure of the sound eye is probably 
due to the discord which still remains between the visual percep- 
tions on the one hand and the sensations arising from the muscular 
sense and general sensibility on the other. The object is seen 
in one direction but felt in another^ or as directed by the eye the 
muscles assume a certain position in order to maintain the erect 
posture, but the common sensibility and the muscular sense en- 
force the necessity of another posture. In this way a confusion of 
the lower brain-centres is produced, which results in vertigo. Dr. 
T. Grainger Stewart has reported {On Giddiness , Edinburgh, 1884) 
a case of nystagmus in which the vertigo was very strongly marked, 
but was at once overcome by holding the eyeballs forcibly quiet, — 
a very strong indication that the giddiness which is sometimes 
present in nystagmus is the result of the rapid changes in the 
position of sensory impressions on the retina. The reason that so 
many persons wdth ocular palsies or with eyes w^hich are not opti- 
cally in accord do not suffer from giddiness is that the habit 
is soon acquired of neglecting the images formed in one retina, 
or, in other words, of using only one eye in conscious vision. 

Aural Vertigo, — In 1861 {Gazette Med. de Paris), P. M6ni6re 
described a case in w^hich a young man was suddenly seized with 
^ a violent vertigo, accompanied by deafness, pallor of the face, ex- 
I cessive sweating, and apparent symptoms of an imminent syncope. 
He fell to the earth without being able to raise himself up, and, 
lying upon his back, could not open his eyes without all the sur- 
rounding objects seeming to whirl in space. The slightest move- 
i ment even of the head increased the vertigo and produced violent 
I vomiting. In a second case, a young woman, after exposure 
during her catamenial period, suddenly became deaf, with violent 
j vertiginous attacks similar to those just described. Five days 
, later she died, and at the autopsy the brain and spinal cord were 

14 



210 DIAGNOSTIC NEUROLOGY. 

found normal, but in the semicircular canals there was a bloody 
exudation of which scarcely a trace could be perceived in the ves- 
tibulum. These and other similar cases led Dr. Meniere to recog- 
nize a form of violent vertigo produced by intense congestion or 
apoplexy in the semicircular canals. Since the publication of the 
papers of Dr. Meniere, numerous articles have appeared describing 
vertiginous attacks in connection with diseases of the middle ear. 
Probably all the diseases of the semicircular canal are liable to be 
associated with vertigo, but the name Meniere's disease should, 
I think, be restricted to those cases in which the vertiginous at- 
tacks are due to an apoplexy or a sudden congestion. I have 
seen violent persistent vertigo resembling that of Meniere's dis- 
ease caused by a small pistol-bullet lodged somewhere in the 
vicinity of the semicircular canals. The relation between the 
aural apparatus and the function of equilibration is undoubtedly 
a close one. As has been shown by Dr. S. Weir Mitchell, the in- 
jection of cold water or of rhigolene into the external meatus gives 
rise to convulsive movements in the rabbit and guinea-pig, with, 
on repetition, the production of a permanently vertiginous state. 
In man, cold water suddenly thrown into the ear will sometimes 
cause excessive vertigo, as in the case of Dr. Mitchell himself, 
in whom a jet of water at a temperature of 52° F. into the left ear 
was immediately followed by disturbance of vision, with move- 
ments of surrounding objects to the left and a fall to the left. 
After getting up, there was swimming of the head and a sense of 
lack of power in the whole left side, with staggering to the left. 
The relation of such an attack as this to various reflex vertigoes 
and epilepsies is a very evident one. The closeness of the rela- 
tion is still further enforced by the fact that in birds many parts 
of the skin are competent under irritations to give rise to vertigi- 
nous phenomena. It does not appear to me that the ease with 
which vertigo is caused by irritations of the external ear proves 
that the external ear is in direct connection with the function of 
equilibration ; the phenomena are readily explained as reflex. 
The cause of the vertiginous attack in labyrinthine disease is as 
yet uncertain. By most physiologists it is believed at present that 
the canals have a very direct relation with equilibration, or are, 
in other words, guiding organs. It is, however, possible that the 
vertiginous sensations which their injuries produce are purely 



i 

i 



DISTURBANCES OF EQUILIBKATION. 211 

of the nature of a reflex disturbance, having no more immediate 
connection with equilibration than have similar vertiginous attacks 
produced by permanent laryngeal and gastro-intestinal irritations.* 

Toxsemic Vertigo. — Cannabis indica, alcohol, belladonna, and 
various other poisons are capable of producing a more or less pro- 
nounced vertigo. In such cases the cause of the vertigo is to be 
recognized by the presence of other symptoms of poisoning, and 
by the history. 

As long ago as the days of Boerhaave, the possible dependence 
of vertiginous symptoms upon irregular gout was recognized. 
This vertigo of lithsemia may be very mild or very severe. The 
attacks may occur at long intervals or may be repeated several times 
in the twenty-four hours. In the severer attacks the whirling of 
objects is very pronounced, and the confusion of mind may be 
marked. In some of these cases there is along with the severe 
vertigo an apparent loss of memory, which is liable to lead to a 
mistaken diagnosis of organic brain-disease. Almost always irreg- 
ular or shooting pains, depression of spirits, irritability, malaise, 
or other evidences of suppressed gout can be noted, and should 
lead to an examination of the urine, which will reveal the presence 
in it of uric acid or the urates, and confirm the diagnosis. In 
some cases gouty vertigo is associated with marked irregularity of 



* VoltolinVs Disease. — A disease which is related to aural vertigo, but pre- 
sents symptoms more closely resembling those of basal meningitis, was origi- 
nally described by Dr. Yoltolini. It is almost absolutely confined to child- 
hood. The attack is sudden, sometimes preceded, however, for some hours 
by restlessness, with shooting pains in both ears. Unconsciousness now de- 
velops, often with great suddenness, and is associated with high fever, great 
restlessness, contracted pupils, and strabismus ; delirium is occasionally 
present, and convulsive movements or evidences of loss of power in the ex- 
tremities may be temporarily developed. Unless the case end fatally, con- 
sciousness is regained in four or five days. During convalescence the gait is 
staggering and often irregular, and deafness is complete. The staggering is 
, usually recovered from, but the loss of hearing is permanent. Yoltolini and 
I Reichel believe that the symptoms are the result of primai^y purulent lahy- 
' rinthic otitis^ but other observers, notably Knapp, affirm that the disease is 
always secondary to meningitis or some septic fever. It is certain that in 
epidemic cerebro-spinal meningitis the infiammation occasionally extends to 
j the labyrinth, and it is probable that the same thing sometimes occurs in 
other forms of meningitis. It seems to me, however, likely that there are 
cases in which infiammation of the labyrinth is primary. 



212 DIAGNOSTIC NEUROLOGY. 

the hearths actioD, which might readily lead to the supposition of 
cardiac diseases and cardiac vertigo. 

Chronic kidney-disease does not very frequently give rise to 
vertigo, but I have seen pronounced vertiginous attacks the only 
decided symptoms of a mild uraemia. In one case, a woman, who 
eventually died in ursemic convulsions, the paroxysms of vertigo 
came on only when no food had been taken for three or more 
hours, and were for a long time supposed to be gastric. The at- 
tacks commenced with extreme pallor of the face, and the appear- 
ance of dark rings under the eyes ; then the woman would speak 
very hesitatingly and slowly, and a moment later cease with a 
dazed expression of countenance. The mental confusion was so 
marked that she did not know where she was or what she was 
doing. After the attack she did not remember what had occurred 
during the paroxysm ; but she never fell in an attack, and she 
would always give some response when spoken to. For a long 
time the attacks were at once relieved by giving a few mouthfuls 
of some hot drink. 

Essential Vertig-o. — There is a class of rather infrequent cases 
in which none of the known causes of vertigo can be discovered, 
and to which the name of essential vertigo, given by Dr. Rams- 
kill, may be wtII applied. It is entirely possible that in some 
instances a hidden peripheral irritation or structural brain-change 
may be the cause of the symptoms ; on the other hand, it is pos- 
sible that in the brain there are centres connected with equilibration 
which are liable to suffer from functional or structural disease and 
thus give rise to vertigo. The recognition of a case of essential 
vertigo implies simply that every known cause has been looked 
for and not found. 



CHAPTER V. 

TROPHIC LESIONS. 

Under the head of trophic lesions I shall consider those alter- 
ations of structure which are apparently dependent upon disease 
of the nerves or of the nerve-centres, or which are, at least, closely 
connected with, and subsequent to, such nervous affections. The 
discussion of the methods in which these trophic lesions are pro- 
duced seems to me beyond the province of the present work, but 
it may be allowable to state my belief that the nervous system 
does exert a direct and immediate influence upon nutrition, — that 
is, upon the structure of the body. A functional act, whether of a 
gland or of a muscle, is nothing more or less than a nutritive act. 
It has been long proved that a nerve may directly so affect the 
nutrition of the muscle-fibre or of the glandular cell as to cause 
the one to contract and the other to secrete ; i.e,, it has been long 
proved that the nutrition of the muscle and of the glandular cell 
may be directly influenced by the discharge of nerve-force, and 
that therefore there are trophic nerves. 

For the purposes of clinical study trophic lesions are divisible 
into those which rapidly destroy all the tissues in their immediate 
course, and those which are not thus destructive. Lesions of the 
second class are for the greater part essentially slow and progres- 
sive, although included in the class are some acute lesions which 
are more or less strictly confined to a single tissue, which, how- 
ever, they do not rapidly destroy. 

ACUTE DESTRUCTIVE TROPHIC LESIONS. 

The destructive trophic lesions are the Decubitus Acutus of 
Continental writers, or the rapid Spontaneous Eschar ; the mal 
perforans, or the Perforating Ulcer ; and Raynaud^s Disease, or 
Acute Symmetrical Gangrene. 

Decubitus. — The term Decubitus is an unfortunate one, which 
really refers to the position assumed by the patient in bed, but has 

213 



214 DIAGNOSTIC NEUROLOGY. 

been transferred to the sore, formerly supposed to result solely from 
pressure due to the position of the bedridden patient. It usually 
attacks the sacro-gluteal regions, but it may appear in any portion 
of the body which is subject to a slight continuous pressure, and is 
not infrequently seen in the heels. The first warning consists of 
one or several erythematous patches, variable in extent and irreg- 
ular in shape. The color may be rosy, but more frequently is dark 
red or even violet. It disappears momentarily upon pressure 
with the finger. In rare cases, and, according to Charcot, only 
when the spinal cord is involved, there is about the erythematous 
patch an apparently phlegmonous swelling, with sometimes acute 
pain. Within twenty-four or forty-eight hours vesicles, or bullae, 
form in the central portions of the erythema. They are red- 
dish or brown-colored, and contain a liquid sometimes colorless, 
but generally opaque and bloody. In rare cases, under careful 
management, the vesicles and blebs wither and disappear without 
further symptoms: usually, however, the elevated epidermis is torn 
or drops off, leaving a bright red surface with bluish or violet 
points or patches. There is now some swelling and sanguinolent 
infiltration of the tissue for some distance beneath the bared surface. 
In the course of a few hours the reddish surface becomes black- 
ish, and a slough of variable extent forms. The whole buttock 
may thus melt down in the course of a few hours. Sometimes 
the process is arrested and the slough separates, but oftener the 
process continues, and, unless the patient die too quickly, the 
deeper muscles, with the nerve-trunks and arterial branches, are 
laid bare, and finally the bones themselves appear. Generally 
death occurs from exhaustion, but, according to Charcot, a second- 
ary purulent affection with metastatic abscesses may follow upon 
the acute bed-sores, and in rare cases gangrenous emboli occur in 
the lungs or in other portions of the body. 

Acute decubitus occurs in disease of the brain and of the spinal 
cord. In cerebral hemiplegia it is always upon the paralyzed side. 

In 1876, A. Joffroy {Arch, de Med., January, 1876) attempted 
to show that in cerebral cases the eschar was always the result 
of lesions of the occipital lobe or of the optic thalamus. This, 
however, is not correct, as the sloughing bed-sore has developed 
after hemorrhage in the external capsule and corpus striatum 
(Broadbent, Lancet, 1876); after focal lesions in the convolutions 



TROPHIC LESIONS. 215 

(De Beurmann, Soc. Anat, March, 1876); after hemorrhage into 
the extra-ventricular nucleus of the striate body (Dusaussay, i6., 
January 21, 1876); after softening of the sphenoidal lobe (Leloir, 
Progres Med,, 1879) ; and after various other lesions. Moreover, 
Charcot has reported four cases in which the occipital lobes or the 
optic thalami were the seat of the lesion without the production 
of the eschar. It would seem, therefore, that acute decubitus 
may follow lesions of almost any portion of the brain. 

Brown-S6quard has demonstrated that if the spinal cord be 
divided half-way through in an animal, acute sloughing ulcers 
will develop in the sacral region, although the part is neither sub- 
jected to compression nor irritated by the urine. The most inter- 
esting fact in connection with this traumatic spinal decubitus is 
that the eschars are limited to the side opposite to the section. In 
man acute decubitus has been noted after hsemato-myelitis, acute 
myelitis, traumatic myelitis, fracture of the spine, etc. It ap- 
pears to be especially connected with destruction of the central 
gray matter of the cord. According to the statistics collected by 
Prof. John Ashhurst, after fracture of the spine decubitus is prone 
to occur in direct proportion as the injury is low down. Sir Ben- 
jamin Brodie, on the other hand {Med-Chir, Trans. ^ 1837, vol. 
XX. p. 148), affirmed that the sloughing bed-sore develops most 
rapidly when the lesion is high up. 

Perforating' Ulcer. — Under the name of perforating ulcer 
{mal perforans) is described a peculiar ulceration which usually, 
but not always, appears upon the foot, and especially affects the 
immediate vicinity of the metatarso-phalangeal articulations of 
the big and the little toe. Often there is but a single ulcer on one 
foot, but there may be as many as three ulcers, and in not rare 
cases both feet are symmetrically attacked. The perforating ulcer 
may appear upon the hand, and there is reason for believing that 
it may even affect the internal organs. Thus, M. L. Terrilldn, in 
the Bidl. de la Soc, de Chir,, 1885, p. 403, reports a case of poste- 
rior spinal sclerosis, with fulgurant pains in the hands and arms, 
in which there were symmetrical ulcers on the thumb and the 
index and median fingers of each hand. Some years ago, in a case 
of gouty dementia {Trans, College of Physicians , Phila., 1884-85), 
I saw a circular ulceration three-fourths of an inch in diameter, 
with smooth, sharp edges, in two or three days eat through the 



216 DIAGNOSTIC NEUROLOGY. 

septum between the vagina and the rectum. It is well known 
that not rarely after extensive burns rapidly-perforating ulcers 
pierce the coats of the stomach, or .more usually of the duodenum, 
with fatal results. 

The first symptom of the perforating ulcer of the foot is gen- 
erally a severe pain. This prodromic pain may, however, be 
entirely wanting. A small hemorrhage or ecchymotic spot now 
appears under the epidermis ; in the course of a few hours the skin 
detaches itself, or more frequently becomes excessively thickened 
intti a large, dry, corn-like mass ; a small slough soon separates, 
leaving the ulceration round, with sharp, acute edges, piercing, it 
may be, only through the skin, but usually to the deeper tissues, 
and in many cases reaching the articulation or the bone. Around 
the ulceration there is apt to be serous infiltration and swelling. 
In rare instances, especially if the patient be put to bed and 
carefully nursed, the perforating ulcer is recovered from without 
loss of bone : somewhat more frequently the patient escapes with 
the throwing off of small necrosed flakes of bone. In most 
cases, however, the bone becomes seriously diseased and a sinus 
forms. In this condition the lesion appears as a small aperture 
leading by a narrow sinus to diseased bone and surrounded 
by thickened superimposed layers of epidermis. The surface 
of the spot is usually cold and anaesthetic, the characteristic 
feature of the ulcer being its insensibility to irritants and its 
freedom from pain during rest. Walking may cause suffering; 
and the fulgurant pains of locomotor ataxia are very frequently 
present, but do not have their origin or focus in the ulcer. 
Erysipelatous inflammation or erythematous exudations are apt 
to occur. Under these circumstances the limb becomes greatly 
swollen and oedematous, and the attack may terminate in ery- 
sipelatous suppuration and death. Except in the rare cases in 
which the ulcer heals early, all the bones of the foot, and indeed 
all the tissues of the foot, become diseased. Not only is the 
joint that is in immediate relation with the ulcer apt to be 
affected, but all the small joints of the foot frequently take on 
an inflammatory action which ends in an anchylosis, or undergo 
ulceration and destruction, resulting in luxations and deformities. 
The nails of the foot usually become brownish, dry, greatly 
thickened, curved, and furrowed. In some cases there is a 



TROPHIC LESIONS. 217 

marked increase in the growth of the hair and in the pigmenta- 
tion of the leg, and the whole foot may be bathed in a peculiarly 
fetid sweat. 

It has been denied that the connection of perforating ulcer with 
disease of the nervous system is other than accidental ; but since 
the paper of MM. Duplay and Morat {Arch, de Med.y 1873) it 
seems to have been almost universally acknowledged that the ulcer 
is the direct or indirect result of various nervous affections. The 
similarity between the perforating ulcer and the ulcerations of 
leprosy was, in 1871, strongly commented upon by Estlander, .nd 
in 1872 M. Poncet, in tracing the relations between leprosy and 
perforating ulcer, found that the nerves in perforating ulcer have 
their connective tissue increased and their fibrils atrophied. Du- 
play and Morat subjected the affected parts in six cases of perfo- 
rating ulcer to microscopical examinations, and in each case found 
an advanced degeneration of the nerves. Morat {Lyon Med.y 
March, 1876) reported a case in which the perforating ulcer fol- 
lowed traumatic section of the sciatic nerve. These observations 
have been confirmed by a number of observers (see Ross, 2d ed., 
vol. i. p. 259), and it would apj)ear that perforating ulcer may be 
due to a disease of the nerve-trunks. 

The great frequency of the affection in locomotor ataxia in- 
dicates, however, that it is not caused solely by lesions of the 
nerve-trunks. It is, of course, possible that the nerve-trunks are 
diseased in those cases of locomotor ataxia in which perforating 
ulcer occurs ; but until this is proved we must consider that the 
perforating ulcer may be produced by various nervous diseases, of 
which the most important are posterior sclerosis and disease of the 
nerve-trunks. In locomotor ataxia this ulceration may be a very 
early symptom ; and if in a case of mal perforans the knee-jerk 
be absent, the diagnosis of locomotor ataxia may be considered 
established, unless positive symptoms of disease of the nerve- 
trunks (such as tenderness) or of myelitis be present. 

Raynaud's Disease. — Under the names of Dead Finger, Anae- 
mic Sphacelus (Myrtle, Lancet, i., 1863), Local Syncope, Erythro- 
myalgia (Mitchell), and Symmetrical Gangrene, there have been 
described by various writers groups of cases which are at present 
generally thought to represent a single disease, commonly known 
as Raynaud^s disease, because the first clear recognition and 



218 DIAGNOSTIC NEUROLOGY. 

elaborate description of it were given by Dr. Maurice Raynaud 
{L^Asphyxie locale, Paris, 1862). The unity of these groups is 
not, however, entirely established. 

In the most acute form of the disease as described by Raynaud 
the beginning of the attack is painless and sudden ; the skin of 
the affected part becomes of a dead-white color, sometimes even 
a little yellowish, and appears entirely devoid of blood. Cuta- 
neous sensibility is lessened or altogether destroyed, so that the 
fingers, which are the parts usually affected, may be pinched with- 
out pain : even when the sensation of contact is entirely lost the 
power of distinguishing heat and cold may be retained. The 
temperature of the parts is very notably diminished ; the power 
of movement is lost. After a time reaction sets in ; the white 
color gives way to a cyanotic tint, which deepens to violet, and in 
some cases to a black compared by Raynaud to that of a spot of ' 
ink. Pressure on the parts now produces whiteness, followed by 
instant return of color on removal of the pressure, showing that 
the discoloration is owing to blood still inside of the capillaries. I 
The parts are at this time swollen. During the stage of reaction 
there is excessive burning pain, which may begin even before the i 
congestion, and in the height of the paroxysm rises to a pros- 
trating agony. In cases of the severest type the local congestion 
soon deepens into gangrene. 

Of the acute form of the affection described by him Raynaud 
makes three stages. The first is the period of invasion : it may • 
last only for some hours, and is never protracted beyond a month. 
The second period is characterized by intense congestion of the 
part; by the perpetual recurrence of pain-crises, which usually 
pass off with an abundant emission of urine ; and by the termi- 
nation in gangrene, which is so rapidly developed that the local I 
destruction is complete and limited in from eight to twelve days, i 
The third stage is that of throwing off the gangrenous tissue, and j 
is of variable length. 

In the chronic type of the disease, according to Raynaud, there i 
are frequent remissions, with violent attacks, which may be pro- [ 
voked by exposure to cold, by a suppression of menstruation, by j 
fright, by a sudden emotion, or even by a mere momentary excite- 
ment. This state may last for several years, and finally end either 
in gangrene or in recovery without loss of structure. 



TROPHIC LESIONS. 219 

The term local syncope is applied to that condition in which the 
parts are excessively pale ; the term local asj)hyxia, to the state of 
congestion. 

Since the publication of Raynaud's article a number of cases 
have been reported upon the continent of Europe, in England, 
and in America. It is questionable whether the local asphyxia 
is not always preceded by the local syncope, and whether those 
cases in which there is no account of a local syncope ought 
not to be considered as a distinct group. It is certain that in 
many of the cases the local syncope had disappeared, if it had 
existed, at the time when the sufferers first came under medical 
observation : moreover, no history of its existence could be ob- 
tained. Some of Dr. S. Weir Mitchell's patients were so intelli- 
gent and so clear in denying a primary syncope that its existence 
is not probable. It was to cases of this character that Dr. 
' Mitchell, believing them to be a distinct group, gave the name 
. of erythromyalgia. On the other hand, in some recorded cases 
, frequent attacks of syncope occurred in the earlier months of the 
disease, and finally gave way to a perpetual local asphyxia whilst 
. the case was being watched by the physician. Thus, Dr. Calcott 
. Fox {Clin. Soc. Trans. y vol. xviii. p. 305) details the case of a 
woman whose fingers for ten years suffered from frequent parox- 
ysms of local syncope, but at last passed into a condition of con- 
tinuous local asphyxia. In these chronic asphyxia cases the pain 
; is increased by allowing the part to hang down, by warmth, by 
^ exertion, or by any act or position which naturally tends to increase 
\ the amount of blood in the affected member. During the con- 
■^ dition of congestion or local asphyxia there is tenderness, which 
may be accompanied by excessive hyper^esthesia or may be re- 
« vealed only by firm pressure. Gangrene may at any time come on, 
jCven in cases which have lasted for many years, but in the most 
i| chronic form of the affection other nutritive alterations are not 
rare : thus, in a case reported by Dr. Fox, occasional blood-blis- 
■ ters formed on the affected fingers, leaving raw surfaces which 
(Were slow to heal, and especially affected the edges of the nails. 
II In such cases some of the fingers may have their phalanges com- 
pletely atrophied and their nails shrivelled up, whilst in other 
/fingers the ends become markedly conical, with their nails curved 
over them. 



220 DIAGNOSTIC NEUROLOGY. 

During the stage of syncope the local temperature is markedly 
abated : thus, M. Lannois {Paralysie vaso-motrice^ Paris, 1880) 
has noted it 4.7° C. below that of the opposite side. During the 
period of congestion the temperature rises, and it has been noted as 
high as 19° F. above that of the opposite side (M. Allen Sturge). 
In one of MitchelPs cases, whenever the foot was suspended in- 
tense congestion came on, accompanied by excessive pain and by 
great rise in the temperature. 

Erythromyalgia appears to affect children more frequently than 
older people. In many of the reported cases the patients had ; 
been previously of robust health; in some instances the neurotic • 
temperament has been strongly expressed ; and in a few cases the 
affection has developed during the progress of diabetes. In sev- 
eral more or less pronounced cases hremoglobinuria has been pres- 
ent, sometimes accompanying the attacks of local syncope, in other! 
instances occurring indifferently to them. In two or three cases • 
ocular troubles have been noted, and once or twice disorders of' 
audition. The reflexes have occasionally been increased, but gen-( 
erally have been normal. 

Although the fingers are the parts most commonly affected, 
other extreme portions of the body are often attacked. The toes 
are frequently the seat of the disease, and in several of Mitchell's t 
cases the gangrene affected a great portion of the sole of the foot. 
All the phenomena of the disease have frequently been observed i 
in the ears, and in a few instances the end of the nose has suf- 
fered destruction. 

The exact nature of Raynaud's disease is still obscure. Thel 
condition known as local syncope is probably due to an iutensei 
vaso-motor spasm, but the cause of such spasm has thus far eluded) 
observation. That it is a general wide-reaching influence isi 
shown by the implication of the ears, nose, fingers, and toes, audi 
by the occasional hsematuria. The occurrence of ischaemic aphasiaj 
(Weiss, Zeitschr.fur Heilh, 1882) strongly indicates that internal 
vascular areas, as w^ell as those of the extremities, may suffer. Noi 
such condition as local asphyxia follows even the complete vaso-i 
motor paralysis of nerve-section, and if it be really paralytic iti 
can be explained only by supposing that the muscles of the walls- 
of the vessels are so absolutely exhausted by over-effort that wheKi 
relaxation follows their local tone is entirely lost. 



TROPHIC LESIONS. 221 

Professor Pitres (Archives de Fhysiologie, 1885, p. 106) found 
in one case of Raynaud^s disease extensive peripheral neuritis, and 
Dr. A. Bidder* lias reported [Arch, fur Klin. Chir., xxx. 810) a 
case in which gangrene of the fingers followed fracture of the 
arm with injuries to the nerve ; but it does not seem probable, 
and certainly is in no way proved, that peripheral nerve-lesion is 
constantly present in the disorder. 

Various facts indicate an obscure but close relationship between 
the dead fingers, scleroderma, and morphoea. In some cases 
of dead fingers a peculiar, raised, wheal-like eruption has been 
present. Further, the repeated coexistence of two such rare 
affections as scleroderma and Raynaud^s disease (for cases, see 
Dr. C. Fox^s article, Clin. Soc. Trans. , vol. xviii. p. 305; also 
Dr. Finlayson, Medical Chronicle^ 1884-85, p. 315) cannot be 
accidental. 

TROPHIC LESIONS NOT ACCOMPANIED BY WIDE-SPREAD 
DESTRUCTION OF TISSUE. 

Trophic changes which are not accompanied by wide-spread 
destruction of tissue and are more or less confined to a single tissue 
are best classified for study according to the tissues affected. I 
shall therefore discuss — first, trophic changes in the skin and its 
appendages; secondly, trophic changes in the muscles; thirdly, 
trophic changes in the bones ; and, fourthly, vaso-motor disturb- 
ances and disorders of secretion. 

TROPHIC SKESr-CHANGES. 

Skin-Diseases. — It is probable that many of the diseases of 
the skin are dependent upon, or at least connected with, affections 
of the nervous system. Thus, Jaining de St.- Just (article ^^Scar- 
latine," Diet. EncycL, 3e serie, vii. 307) relates the case of a 
hemiplegic in whom for two days the eruption of scarlatina was 
limited to the normal side, and Chevalier {TMse, Paris, 1878) 
describes a case in which variola was confluent and hemorrhagic 
upon the paralyzed side but discrete upon the other ; and in a case 
of M. Bouilly (cited by Arnozan), during an attack of smallpox 

* Considering the possible lesion to blood-vessels, and the free use of the 
gypsum bandage, not much weight can be attached to this case. 



222 DIAGNOSTIC NEUROLOGY. 

no pustules appeared upon the leg the sciatic nerve of which had 
previously been divided. Our present knowledge of this subject 
is, however, so scanty that a most important field of research 
remains almost uncultivated. That desquamation may be effected 
by nervous influence is shown by a case reported by N. Bouilly 
(Arnozan, Des Lhions trophiques, Paris, 1880, p. 151) : a man had 
a neuroma of the sciatic nerve, and below the tumor the epidermis 
was covered with small, dry, blackish or brownish scales, easily 
detached, and having an appearance like that of ichthyosis; after 
removal of the neuroma the skin resumed its normal appearance. 
Ballet and Dutil {Progi^^s Med,, May, 1883) reported three cases 
of skin-alteration resembling ichthyosis in disease of the spinal 
cord, and M. Gautier one in a person suffering from lead palsy. 
Tischer has seen exfoliation of the skin follow the course of an 
inflamed nerve, and Schiefferdecker the skin thickened, scaly, 
brown, perpetually covered with malodorous sweat, and adorned 
by hypertrophic nails and hair. (See Ross, loc. cit, p. 248.) The 
pigmentation of the skin which sometimes occurs in Raynaud's 
disease has already been pointed out, and it is probable that 
the bronzing which is characteristic of Addison's disease is due to 
nervous influence. According to Morselli, there is a peculiar form 
of vitiligo seen in the insane in which whitish spots surrounded 
by pigmented borders are more or less symmetrically arranged 
about the head and neck. Bourneville and Poirier (Pro^^?'^ Mid,, 
1879, No. 24) have reported somewhat similar discoloration of 
the skin in a person suffering from cerebral tumor, whilst Du- 
menil has noted pigmentary alterations following chronic neuritis. 
G. Rossolymmo {Arch, fur Psych., 1884, vol. xv. p. 723) has re- 
corded a case of a person suffering fron; locomotor ataxia, the 
right half of whose forehead, cheek, and nose, etc., became cov- 
ered with irregular sharply-bounded spots in which the hair turned 
white. 

In 1831, Dr. R. Bright called attention to the possible etiologi- 
cal dependence of herpes zoster " upon distention of the sentient 
nerves/^ In 1853, Romberg {Syd. Soc. D^anslaUons, vol. i. p. 84) 
also noted the seeming connection between herpes zoster and inter- 
costal neuralgia. In 1855, M. Delioux suggested that herpes 
zoster might be due to neuritis; and in 1859, M. Charcot pub- 
lished cases of herpes following upon a wound of the nerve. 



TROPHIC LESIOXS. 223 

These observations have been abundantly confirmed (see Eoss^ vol. 
i. p. 243)^ and it has been shown that neuritis may give rise to 
herpetic and other forms of eruption. The first stage of acute de- 
cubitus is a bulla, and pemphigus has been noted in various ner- 
vous diseases. (See Ross, loc. cit., p. 247.) Papular and pustular 
eruptions after neuritis have been noted by Charcot and by Yul- 
pian; whilst the quickness with which erythematous eruptions and 
urticaria are developed by certain forms of gastric irritation 
demonstrates that they are often nothing more than reflex nervous 
phenomena. I have seen a furious urticaria replace the chill- 
stage of a malarial paroxysm ; Charcot reports a case of locomotor 
ataxia in which enormous wheals covered the parts through which 
the pains were darting ; and ecchymotic spots not very infrequently 
appear during the pain-crises of posterior sclerosis. 

In the elaborate studies made by Mitchell, Morehouse, and 
Keen of the results of gun-shot injuries of the nerves (see 
Mitchell, Injuries of Nerves)^ it was shown that in many cases 
the eruption following the nerve-injury is composed of small 
acutely-pointed vesicles, which may well be described as eczema- 
tous : eruptions of similar character have been also noted after 
injuries to the ulnar nerve (see Mitchell, p. 154). 

The so-called '^ glossy skM^ {causalgia of Mitchell) is a very 
, curious alteration of the skin, which was first distinctly described 
' by Mr. Paget, although noted as early as 1813 by Mr. A. Den- 
, mark. It occurs as the result of injuries to nerves and the con- 
sequent neuritis. The afifected skin has the appearance of thinness, 
( is very smooth, glossy, and shining, as though varnished, is 
usually deep red or mottled, or red and pale in patches, free 
from hair, and often looks as if it were tightly drawn over the 
" tissues below. This condition of the skin is always associated 
with a horrible burning pain, which frequently rises to agony, 
' and often precedes the nutritive changes. Over the altered 
surface come and go groups of vesicles, whose eruption is attended 
I with a temporary amelioration of pain. Dr. Mitchell believes 
, that this causalgia may result from central nervous disease; but the 
ij case upon which he appears to have based this opinion resembles 
\] so closely spinal meningitis with a descending neuritis that in 
/ the absence of an autopsy the diagnosis is exceedingly uncertain. 

Hair and Nails. — Trophic changes frequently take place in the 



224 DIAGNOSTIC NEUROLOGY. 

hair and in the nails. The whitening of the hair which occurs 
during an attack of migraine will be discussed under the head of 
Migraine. The change which occurs in the color of the hair from 
nervous influence is very remarkable, and at present inexplicable. 
There is a prominent surgeon in this city the hair of whose head 
is said to undergo a distinct temporary alteration whenever he 
has a severe, trying surgical operation on hand. It is well es- 
tablished that the hair may, under emotional excitement, change 
its color entirely and permanently during the course of a few 
hours or a few days. One of the best authenticated of modern 
instances of such a phenomenon is reported by D. P. Barry, staflp- 
surgeon in the British army [Medical Times and Gazette^ April, 
1859, vol. i. p. 367). Near the close of the Sepoy Rebellion a 
Bengalese was brought in and questioned previous to execution. 
While actually under observation, within the space of half an 
hour his hair became gray on every portion of his head, it 
having been glossy jet-black at the beginning of the examination. 
The attention of the by-standers was first attracted by the ser- 
geant, whose prisoner he was, exclaiming, ^^He is turning gray !'^ 
Gradually but decidedly the change went on until a uniform 
grayish color was reached. The older records contain various 
reports of this abrupt canities. Thus, Ludovico Sforza, having 
been taken prisoner by Louis XII., his mortal enemy, was seized 
with such terror that the night before he suffered punishment his 
hair, which had been before very black, became very white, so 
that his guards the next day thought him to be another person. 
Montaigne comments upon a gentleman one-half of whose beard 
and one eyebrow suddenly became white in consequence of a vio- 
lent emotion. Guarini da Verona suddenly turned gray when the 
loss at sea of the Greek manuscripts which he had with infinite 
toil collected at Constantinople was announced to him. Bichat 
{Anatomie Generate, iv. 815) and M. Rayer {Traite des Maladies 
de la Peau, iii. 733) each record a case in which the hair turned 
white during a single night ; and a number of cases have been 
collected by J. Moleschott [Physiolog, Skizzenbuch, Giessen, 1861) 
showing that a similar alteration may take place more gradually 
in the course of a few days. 

Peripheral nerve-lesions undoubtedly also affect the nutrition 
of the hair. In causalgia the hair usually falls out, — a result | 



TROPHIC LESIONS. 225 

which in animals habitually follows section of the nerve. On the 
other hand, both Pouteau and Larus saw the hair become coarse, 
hard, and stiffly erect in traumatic neuralgias. Bellingeri also 
noticed the hair becoming thicker and harder and growing faster, 
whilst in a case recorded by Hamilton, during neuritic symptoms 
following a lancet-wound, the arm became thickly covered with 
hair. (See Mitchell, Injuries of Nerves, Phila., 1872, p. 164.) In 
a case of arsenical poisoning, with wide-spread neuritis and com- 
plete degeneration of the muscular structure, which I watched for 
many months, the legs became covered with a thick growth of hair 
several inches long. 

As was, I believe, first observed by Dr. Mitchell, the growth of 
the nails is habitually arrested upon the paralyzed sides in cases 
of cerebral hemorrhage. This is easily demonstrated by staining 
the nails of the two hands with nitric acid : frequently a lunate 
appearance of growth at the bottom of the nail is the first evi- 
dence of returning functional power. After total section of a 
nerve the nails are apt to become clubbed, and in rare cases pain- 
less whitlows are developed. In traumatic neuritis, especially in 
connection with causalgia, nails to which the affected nerves are 
distributed undergo remarkable changes. The alteration consists 
in a curve in the long axis and extreme lateral arching, and some- 

1 times a thickening of the cutis beneath the end of the nail, 
whilst the skin is retracted from the base of the nail so as to 
leave a partially-exposed sensitive matrix. In certain cases of 
nerve-lesions the nails become dry, scaly, and cracked, and in 

i others they undergo atrophy ; sometimes, as in the case reported 

■ by Hayem, they fall out entirely. 

j As will be explained in discussing the trophic lesions of bones, 
it is not rare for the teeth to fall out in locomotor ataxia, on ac- 
count of the destruction of the alveolar processes. 

TROPHIC BONE-CHANGES. 

I Peripheral Nervous Diseases. — Trophic alterations of the 
(bones may be produced by disease of the nerve-trunks. M. 

Avezou {Thdsej 1879) has collected a number of cases showing 
' that nerve-lesions can produce atrophy of the bones, and Lobstein 
' details a case of a man who had an injury of the sciatic and crural 

nerves, in whom, after death, the femur on the injured side was 

15 

i 



226 DIAGNOSTIC NEUROLOGY. 

found to weigh only one-third that of the normal side. Ogle 
records a case {St. George^ s Hospital Reports, 1871) in which sec- 
tion of the median nerve was followed by wasting of the bones 
through the whole distribution of the nerve. It is well known 
that in poliomyelitis of the young arrest of development follows 
the alteration of the spinal cells. The facial troplioneurom 
of Romberg is possibly of this nature, — an arrest of develop- 
ment of the bone following poliomyelitic atrophy of the facial 
muscles.* M. Bouchut {Gaz. des Hopitaux, 1878, p. 629) has re- 
ported the case of a child, seven years old, in whom an ascending 
neuritis, the result of an injury, had been followed by marked 
lessening in the bones of the arm, as well as by arthropathies, of 
which it is uncertain whether they were trophic or rheumatismal. 
Central Nervous Disease. — Many years ago it was noted that 
the bones of insane patients are frequently broken, and that mul- 
tiple fractures are quite common. These constantly-recurring 
fractures have been brought forward by the opi)onents of insane 
asylums as evidence of cruel and rough handling on the part of 
attendants, but it is now proved that the causes of the accidents 
lie chiefly in the bones themselves. Under certain circumstances 
the bones of persons suffering from general paralysis, and probably 
the bones of those suffering from other forms of insanity, become 
enlarged and brittle. When broken, these bones unite easily 
and very rapidly, with the formation of an excess of callus, so 
that there may be a large tumor at the seat of fracture. After 
death in such cases, it will be found that the bones are notably en- 
larged; that they are so soft as to be readily cut with a knife; 
and that there exudes from the cut surface a pink or reddish san- 
guinolent juice, which, when placed under the microscope, is found 
to contain large quantities of nuclei and imperfectly-developed 
cells. On section, such bone will be found to be more porous than 
normal, and the microscope will reveal great dilatation of the Ha- 
versian canals, which are filled with a fluid containing embryonic 
cells. A very curious feature in this form of bone-disease is that 
it attacks almost exclusively the skeleton of the trunk. It is the 
ribs, the bones of the pelvis, or the vertebrae that are affected. 

^ For an account of this affection, see Fremy, Etude critique sur la Trophct^ ' 
nevrosefacialej These^ 1873; also Lande, Aplasie lamiyieuse progressive^ These,] 
1870. 



TROPHIC LESIONS. 227 

Dr. Moore is stated to have made a chemical analysis of these 
bones, and to have found a remarkable lessening of their inor- 
ganic matter. I have seen one case in which an osteoporosis like 
that of general paralysis existed in a patient who was supposed to 
be suffering only from chronic alcoholism. As, however, I saw the 
man but once during life, and as the history was very imperfect, 
the diagnosis may have been erroneous. 

TROPHIC CHANGES IN JOINTS. 

The most important of the changes which are produced in 
bony tissues by diseases of the nervous system are those which 
are connected with alterations of the joints. 

Hemiplegic Arthropathies. — As was especially pointed out 
by Prof. Charcot, there is a peculiar form of arthritis connected 
with hemiplegia which is especially apt to occur when the paral- 
ysis is dependent upon minute foci of softening. Very often this 
form of arthritis is supposed to be due to rheumatism, and the 
patient is believed to be suffering from another disease — acute or 
subacute rheumatism — supervening on the attack of hemiplegia. 
The diagnosis between trophic and rheumatic arthritis is to be 
made by attention to the following particulars : first, the hemi- 
plegic arthritis develops about the time at which late muscular 
contractures usually come on ; secondly, the trophic inflammation 
of the joints, at least in the early stage, is limited to the affected 
side; thirdly, the pain may be moderate, but the tenderness is 
excessive; fourthly, the swelling, which is pronounced, develops 
rapidly, and is accompanied by distinct oedema, with pitting on 
pressure. 

The history of hemiplegic arthritis differs entirely from that of 
chronic rheumatism. In rheumatic arthritis there is no tendency 
j to the development of pus, and little or no tendency to the break- 
ing down of bony tissue, the effusion within the joint being serous 
. and remaining so for months. The cartilages may be removed, 
ij but the bone beneath the cartilage becomes hard, thickened, and 
of irregular growth, and has very little tendency to ulceration 
and destruction. Frequently osteophytes are found in the effu- 
sion. In the joint affected with hemiplegic arthritis, although 
[ the process is very slow and the arthritic changes may continue 
I for months and even years, there is a tendency to the formation 



228 DIAGNOSTIC NEUROLOGY. 

of purulent liquids, and to the destruction not only of the cartilages 
but also of the bone. 

In a patient of my own there was complete hemiplegia on the 
right side^ with aphasia. She complained greatly of pain in the 
leg and arm. The moment she thought the limb was to be ex- 
amined she would scream with the mere fear of contact : when 
the joint was touched, the emotional disturbance became uncon- 
trollable. The joints were swollen, very glossy, and hard to the 
touch. When she first came under observation the affection was 
confined to the hemiplegic side, and w^as evidently not rheumatic. 
There was no history of rlieumatism, and the joints did not pre- 
sent the peculiarities of rheumatic joints. For a year or more the 
joints remained in the same condition, but finally those of the 
other side became slightly affected. After death the original lesion 
of the brain was found to have been a large hemorrhage in the 
neighborhood of the claustrum, entirely destroying the external cap- 
sule: hence the complete hemiplegia and aphasia, and the trophic 
lesions. On opening one of the joints, I found that it contained 
a moderate amount of purulent serum, that the cartilages were 
almost entirely destroyed, and that the surface of the articulations 
was largely affected and eroded. After the bones were boiled, the 
articulating surfaces were found to be exceedingly porous, and in 
some places part of the bone had been eaten away. The bones of 
the arm were very light, owing to the thinness of their shafts. 
There had been not only a destruction of the joint, but also an 
atrophy of the shaft of the bone. 

Spinal Arthropathies. — Changes in the joints which must 
be looked upon as trophic are not rare phenomena in locomotor 
ataxia. They belong among the prodromic symptoms, usually 
being developed after the fulgurant pains, but before marked dis- 
order of co-ordination. In rare instances they are of diagnostic 
importance. In any case their presence, associated with loss of 
knee-jerk or with fulgurant pains, would be suflBcient for the 
diagnosis of incipient locomotor ataxia. Sometimes, though rarely, 
they are developed in advanced stages of the disorder, but almost 
invariably under these circumstances they affect an upper ex- 
tremity, and therefore really represent the early changes in the 
spinal cord, up which the disease is ascending. 

Dr. M. Ball {Des Arthropathies consecutives, Paris, 1869) shows 1 



TROPHIC LESIONS. 229 

that in its typical development there are three stages of sclerotic 
arthropathy. In the first stage the joint suffers from hydrar- 
throsis. The effusion is serous, and never contains blood, pus, or 
albuminous flocculi. It is not limited to the articular cavity, but 
distends the bursa or the fibrous tissues around the joint, and 
may, indeed, involve for a considerable distance the whole leg. 
The joint at this time is enormously swollen, hard, usually pale, 
and so resistant as not to pit on pressure. The amount of fluid 
which it contains is very large. Thus, in a case reported by Dr. 
Ball, three hundred grammes of liquid were taken out of the joint 
by three successive punctures. There is no inflammation of the 
joint. At a post-mortem examination made by Dr. Ball, the syno- 
vial membrane did not show any abnormal vascularity, and there 
were no vegetations in the articular cavity. In rare cases the effu- 
sion is absorbed, but usually the second stage is soon developed. 
At this time the joint is much swollen, hard, and bony, with an 
evident increase in the size of the bony surfaces. In the third 
stage there is destruction of the articulating surfaces, and in some 
cases so much absorption of the bone and changes in the ligamen- 
tous structure as to produce great alterations in the power of move- 
ment. The epiphyses especially undergo atrophy and change ; the 
ligaments are elongated, probably as a consequence of prolonged 
stretching by the excess of fluid, and at last a condition of subluxa- 
tion or perhaps of complete luxation of the joint occurs, so that 
the ataxic may be able voluntarily to put out of joint a shoulder, 
a knee, or other joint without pain, though marked grating can 
be felt during movement. In a case reported by M. Oulmont, the 
patient was able to bend his leg in such a manner that the sole 
of the foot could be placed upon the internal surface of the thigh. 
Tabetic joints usually develop with great rapidity, and in most 
cases without apparent cause. The patient will go to bed in the 
evening with the joint seemingly in its normal condition and 
wake up with it swollen in the morning. There are recorded 
cases, however, in which these arthropathies followed exposure 
to damp or slight traumatisms. In several of my own cases 
the patients insisted that they had broken the foot or ankle during 
some moderate exertion. It is probable that in these instances 
a slight sprain was followed in the course of a few hours by 
immense exudation. 



230 DIAGNOSTIC NEUROLOGY. 

Usually in the beginning of, as well as later in, the attack, 
the joint is not red, and there is little or no discoloration ; but 
M. Michel speaks of having seen great enlargement of the veins, 
and even rupture of the large saphenous vein, which caused the 
whole leg to turn black. In one of my cases a similar blacken- 
ing of the limb was asserted to have accompanied the first de- 
velopment. It is doubtful whether there is ever any fever or 
local heat, although M. Ball reports one or two cases in which 
fever was said to have existed in the beginning ; but, as no ther- 
mometric studies seem to have been made, there is considerable 
doubt as to whether the general temperature was really elevated. 

MM. Charcot and Bouchard have noted in two instances a 
peculiar articular creaking or crepitus, preceding by some days 
the serous exudation. 

Spinal arthropathies are most commonly observed during the 
second stage of M. Ball : such joints are large, very hard, evi- 
dently containing much water, and at the same time having an 
increase of their composite bones, are perfectly indolent, and free 
from redness or heat, although attempted movements usually cause 
pain. In one of my own cases, in which it was doubtful whether 
the alteration of the joint should be considered hysterical or 
ataxic, there was marked hypersesthesia. It is possible that such 
hypersesthesia may be looked upon as a diagnostic means of dis- 
tinguishing between the hysterical and the ataxic joint. From 
the rheumatic joint the ataxic is at once separated by the absence 
of heat, excessive tenderness, and pain. Care is sometimes neces- 
sary not to mistake the fulgurant pains of the locomotor ataxia, 
which may dart and play about a joint, for the true joint-pains of 
a rheumatism. 

The ataxic arthropathy is sometimes unilateral, but is very fre- 
quently more or less symmetrical. It attacks especially the knees, 
and next in order of frequency the other joints of the lower ex- 
tremities, but it may occur in any joint of the body. In eighteen 
cases collected by M. Ball, the knees were affected in eleven 
cases, the shoulder in three, the coxo-femoral articulation in one, 
the metacarpo-phalangeal joints twice, and the elbow once. The 
small joints of the foot are frequently attacked, giving rise to a 
peculiar deformation to which the name of the tabetic foot {pied 
tabetique) has been given by Prof. Charcot. The outer border of 



TROPHIC LESIONS. 



231 



the foot is often enormously thickened, so that the inner border 
does not touch the ground. A peculiar impression of the foot is 
thus produced, like that of the accompanying drawing, reproduced 
from a paper in Bull. Soc. des Hop,, Paris, November 4, 1885. 



Pig. 6. 




In a case of this character of my own the arch of the foot 

was entirely lost, so as to bring the plantar surface continuously 

to the ground from the heel to the toes. The change had been 

accompanied by an increase in thickness over the tarso-meta- 

tarsal articulation, so that, although the foot rested flat upon the 

ground, this region was very prominent. The prominence was 

most marked on the inner edge. The deformity was greatest in 

the left foot. 

Fig. 7. 




At the autopsy in my case, besides advanced posterior spinal 
sclerosis, the following condition was found : 

The ankle-joint, which was the first examined, exhibited no 
enlargement, nor did the articulating surfaces of the tibia and 



232 DIAGNOSTIC NEUROLOGY. 

fibula yield any evidences of disease. The articulating surfaces 
of the astragalus, however, were here and there denuded of carti- 
lage and much roughened. Similar changes, though slight, were 
noticed in the calcaneum, but it was in and about the joint formed 
by the internal cuneiform and first metatarsal bones that the great- 
est amount of change had occurred. The cartilage had entirely 
disappeared from its upper portion. Here the two bones had be- 
come firmly united. The microscope revealed a continuous osse- 
ous structure from one to the other. The lower portion of the 
joint, which was equivalent to about three-fourths of its entire 
area, was filled by continuous or adherent surfaces of cartilage, 
while here and there a narrow chink, representing the original 
cavity of the joint, was left. The bones appeared enlarged and 
distorted, and an examination of their internal structure showed 
that the cancellated tissue had been replaced here and there by 
small masses of dense ossific deposit. 

The middle cuneiform and second metatarsal bones were partly 
crowded over the internal cuneiform and first metatarsal bones, 
and presented lesions similar to those just described. The heads 
of the two metatarsal bones had in one place become continuous, 
and one section revealed an isthmus of bone uniting an angle of 
the internal cuneiform with the head of the second metatarsal. 

The general impression given by the study of these lesions was 
that of a mass of bones which, being at one time softened, had 
been mechanically distorted and displaced. The absorption or 
deposition of bony tissue appeared to follow no rule, nor did the 
destruction of the cartilage distinguish itself by any peculiarity 
other than that it seemed to precede the changes in the bones. 

Much more rare than the tabetic foot is the tabetic hand, of 
which I have never seen an example. The cut on the opposite 
page, after Ball, indicates that it is scarcely less characteristic and 
peculiar than is the pied tabetique. 

The portions of the bone most prone to be attacked in locomo- 
tor ataxia are the epiphyses : although first much enlarged, they 
finally undergo atrophy, which may reach such an extreme that 
only the traces of the head of the bone can be found, surrounded 
very frequently by long stalactitic points. Although Arnozan 
seems to deny it, and there are very few, if any, autopsies to 
prove it, the clinical evidences show very clearly that the stage 



TROPHIC LESIONS. 233 

of atrophy is preceded in most if not in all cases by one of hyper- 
trophy. M. Liouville (quoted by Arnozan) found in one case of 
scapular arthropathy dilatation of the Haversian canals, which 
were filled with embryonic cells and fatty matter. M. Regnard, in 
making an analysis, found the osseine in normal quantity, but the 

Fig. 8. 




phosphates very remarkably diminished and the fatty matter 
enormously increased. These histological and chemical results 
show a strongly-marked resemblance between the bones of loco- 
motor ataxia, of osteomalacia, and of general paralysis. 

Not rarely in locomotor ataxia the shaft of the bone is also 
attacked, and fractures from muscular exertion during life are in 
such cases very common. Although in various post-mortems the 
shafts of such bones have been found much atrophied and very 
hard, yet there is reason for believing that the pathological process 
is not essentially different from that which occurs in general paral- 
ysis. In cases of fracture there is an enormous and excessively 
rapid formation of callus, whilst in some instances portions of 
the bone have been found hard and atrophied and other parts 
increased in size and spongy. Again, one femur has been found 
atrophied and its fellow enlarged and in a condition similar to 
that which occurs in general paralysis. It would, indeed, ap- 
pear as though various diseases of the nervous system produce 
changes in bone which may end in atrophy and hardness or 
may result in a permanent production of a condition allied to 
osteomalacia; since not only have the alterations which have just 
been described been met with in general paralysis and in loco- 
motor ataxia, but Lagrange {Thhe, 1874) has reported a case of 
scleroderma with neuritis in which the phalanges were extremely 
atrophied and their articular surfaces lost, while the microscope 



234 DIAGNOSTIC NEUROLOGY. 

revealed structural lesions very similar to those which occur in 
general paralysis and locomotor ataxia, — namely, engorgement of 
dilated Haversian canals with fat-granules and embryonic cells. 
There is also reason for suspecting that similar changes in the 
bones occur in leprosy, although close studies are at present a 
desideratum. 

Loss of Teeth. — A curious result of trophic bone-changes which 
is not very rare in locomotor ataxia is a rapid loss of the teeth. 
This occurs entirely independently of the condition of the teeth 
and gums, which may be perfectly sound and free from all sore- 
ness. The attention of the patient is suddenly awakened by the 
teeth becoming loose and dropping out one by one at intervals, 
sometimes so rapidly that all the teeth of one jaw are lost in the 
course of a few hours or days. It is rare for the two jaws to 
be simultaneously attacked. In some instances a shedding of the 
teeth en masse has occurred during sleep and threatened stran- 
gulation. The edentulous jaw-bone continues to waste until it 
is reduced to a mere shell. Although there is no soreness in the 
gums or teeth, it almost invariably happens that for many months 
or even years preceding the lesion the patient suffers from violent 
pains about the face. These pains are shooting, and, even though 
they occur in regular crises and are associated with loss of sensi- 
bility, they are usually supposed to represent simple trigeminal 
neuralgia. They are, however, the fulgurant pains of locomotor 
ataxia, and are caused by the involvement of the nucleus or 
roots of the trigeminal nerve in an ascending posterior sclerosis. 
The falling of the teeth is due to the destruction of the alve- 
olar processes by progressive trophic changes, which in the jaw- 
bone proceed in a manner entirely parallel with those of the long 
bones. 

If posterior sclerosis begins in the upper portion of the spinal 
cord, the loss of the teeth occurs early in the affection, because it 
represents the stage preceding loss of co-ordination. When, how- 
ever, as is usually the case, the degeneration of the spinal cord is 
an ascending one, it may not reach the trigeminal nucleus until 
late in the general disorder. 

Artificial Spinal Arthropathies. — The only attempts to pro- 
duce by operations upon the nervous centres bone-lesions similar 
to those of locomotor ataxia which have been crowned with any 



TROPHIC LESIONS. 235 

success have been those of Dr. Giacomo {Soc. de Biologiey March, 
1885, p. 156). This investigator cut in a very large dog the 
posterior roots of three lumbar nerves between the ganglia and 
the cord. After some months the joints of the left foot became 
enormously swollen and cedematous, without increase of sensibility 
or of temperature. At the autopsy it was found that degeneration 
had occurred in the spinal cord, and that the lesion of the joint 
corresponded in position with the secondary spinal alterations. 

TEOPHIC LESIONS OF MUSCLES. 

Of all the trophic disturbances, the most important to the 

practical neurologist are those which occur in the muscles. The 

ganglionic cells immediately connected with the nutrition of the 

I muscles are grouped together in the anterior cornua of the spinal 

cord. In any nervous disease, so long as the spinal cells and 

their connection with the paralyzed muscle are intact, no rapid 

, change occurs in the structure of the muscle. Whenever there 

' is a destruction of the spinal cells or an interruption of their 

pathway along the nerve, the muscle at once begins to undergo 

degeneration, and in from five to ten days such change is readily 

demonstrated. The early appearance of trophic lesions in a para- 

1 lyzed muscle, therefore, proves that the lesion is situated either in 

the ganglionic spinal cells or in the motor nerve-trunk. 

! The detailed discussion of the anatomical changes in the mus- 

] cles is foreign to the intent of the present volume. Suffice it 

I to state that atrophy with granulation of the muscle-fibre is first 

' apparent, then distinct fatty degeneration of the muscular fibres, 

with marked proliferation of nuclei, and finally a replacement of 

1 the muscle-fibre by cellular tissue, until at last the muscle is re- 

I duced to a fibrous band. 

I When a muscle is degenerating for want of spinal influence, it 
\ first loses its power of responding to rapidly-interrupted faradic 
j or chemical currents, then to slowly-interrupted faradic currents, 
, then to slowly-interrupted chemical currents, and lastly to slowly- 
reversed chemical currents. At this time occurs with the galvanic 
! current the so-called reaction of degeneration, first discovered by 
i Brenner, and since elaborated by Ziemssen and by Erb. To com- 
prehend this reaction it must be remembered that it is obtainable 



236 DIAGNOSTIC NEUROLOGY. 

only by applying the electrode to the muscle. This is evidently 
connected with the fact that a muscle artificially separated from 
its nerve does not readily respond to the faradic current, although 
its answer to the slow galvanic current is the same as is that of 
the nerve.* According to some authorities, the separated muscle, 
before it gives the reaction of degeneration, responds more slowly 
than normal to the current: this is the so-called modal change. 
Even at this time the muscle may respond to milder currents 
than it normally notices. The divided nerve rapidly loses its 
power of answering the faradic current; to the galvanic current 
it is often at first abnormally sensitive, but soon its power of 
response declines to extinction. These quantitative changes are 
not attended with any qualitative alterations : the formula remains 
unchanged throughout. 

In accordance with what has just been said, if the electrode be 
applied to a nerve-trunk of a degenerating muscle, it will be found 
that reaction is diminished in quantity but not altered in quality. 
When a galvanic current of very moderate strength is used, and 

^ I have never experimented with the action of galvanic and faradic cur- 
rents upon isolated muscles, and authorities are somewhat at variance in 
regard to such action. Hughes Bennett aflSrms [Electro- Diagnosis^ p. 36) 
that muscles have no true faradic excitability. Erb, on the other hand 
(Electro-Ther^apeuticSj p. 76), states that the muscle has its own irritability. 
The nerve-endings in the muscles are so closely associated with the muscle- 
fibre that it is not possible by any mechanical procedure to separate one from 
the other, and any galvanic or faradic current which is thrown into the mus- 
cle must act upon the peripheral nerve-filaments. By the action of curare 
we are, however, enabled to paralyze the motor nerve-ending, and physio- 
logically to isolate the muscle-fibre without injury to it. Under these cir- 
cumstances, according to Landois and Sterling, faradic contractility of the 
muscle-tissue is much diminished, but not lost. It would appear that the 
muscle-fibre is capable of responding to any form of electricity, but is much 
more sluggish than is the nerve-tissue. Hence it responds more slowly, and 
it is necessary for the current to continue for a certain length of time in order 
for any response to occur. 

There is no essential diff'erence between the faradic and the galvanic current. 
All the chemical efi^ects of the galvanic or chemical current are produced by 
the induced current obtained from the magneto-electric dynamos. The 
muscle being less sensitive than the nerve simply requires more time for the! 
reception of the impression. On account of the exceeding brevity of faradic I 
currents, it responds less readily to them than does the nerve. It responds ju^^' 
us badly to the galvanic or chemical current, provided such current be very! 
rapidly interrupted. 



TROPHIC LESIONS. 237 

the negative pole (cathode) placed over the normal muscle, but 
not over its motor point, a strong contraction occurs at the closure 
of the circuit; when, however, the positive pole (anode) is placed 
over the normal muscle, the contraction is much less ; in neither 
case is there any contraction when the circuit is broken : in other 
words, with the normal muscle and a feeble current we obtain 
good cathodal closing contraction, slight anodal closing contrac- 
tion, and no motion whatever at either cathodal or anodal opening. 
When a current of sufficient power is used, opening contractions 
are produced, and the anodal contraction is greater than the ca- 
thodal. The "reaction of degeneration^' consists merely in a more 
or less perfect reversal of the above formula. The anodal (positive 
pole) closure then causes a stronger contraction than the cathodal 
(negative pole) closure. When there is only a slight degree of 
degeneration present, there is a correspondingly slight increase 
of anodal closino^ over cathodal closino; contraction. A minimum 
degeneration would be indicated by an equality of the two closing 
contractions. 

These alterations in the electrical reactions of a degenerating 
muscle are readily formulated, and in this way perhaps will be 
more readily grasped by the student. The symbols are as follows : 
An CI C represents anodal closing contraction ; An O C repre- 
sents anodal opening contraction ; Ca CI C represents cathodal 
closing contraction; Ca O C represents cathodal opening con- 
traction : < represents is less than ; > represents is more than 
(the point of the < being towards the lesser quantity). 

Then the formulas are : 

An CI C < Ca CI C 1 . i 

* ^ ^ ^ ^ ^ ^ muscle normal. 
An O C> Ca O C) 

An CI C = Ca CI C \ , . ^ 

4QP p OP ( muscle in nrst stage oi degeneration. 

An CI C > Ca CI C 1 muscle in more advanced stage of de- 
AnO C<CaO C ) generation. 

After the reaction of degeneration (D R of some authors) has 
I been established, if the muscle continue to undergo change, the 
galvanic irritability slowly diminishes, stronger and stronger cur- 
rents being required to produce an effect. When a certain stage 
f is reached, all reactions cease, save a feeble An CI C, and at last 
this is lost, and the muscle does not respond at all. When recovery 



238 DIAGNOSTIC NEUROLOGY. 

occurs^ the electrical reactions of the muscle pass upward along 
the pathway they have descended. 

The practical importance of the reaction of degeneration is 
greatly lessened by the circumstance that its demonstration usu- 
ally requires much skill and patience, and that it probably is never 
present when a muscle retains its integrity as regards the faradic 
current. For the purposes of diagnosis the failure of response to 
the rapidly-interrupted faradic current is usually a sufficient test 
of the condition of a muscle. When a muscle loses its power 
of responding to the rapidly-interrupted faradic current in a week 
or ten days after the occurrence of paralysis, whether the reaction 
of degeneration can or cannot be satisfactorily demonstrated, the 
inference is positive that trophic changes are taking place in the 
muscle. If a few days later such muscle is unable to respond to 
any faradic current, this inference becomes a certainty. For the 
purpose of prognosis the study of the reaction of degeneration 
may be necessary, but it will, according to my experience, often be 
found disappointing. 

Diseases which cause Muscular Degeneration. — A sudden 
loss of power in the muscle followed by rapid trophic changes 
must depend upon an interruption of the pathway between the 
spinal cells and the muscle, or upon disease of the cells them- 
selves. The pathway may be interrupted by traumatism, or by 
neuritis of an acute and violent type, whilst the cells may be 
acutely diseased as the result of a violent and general inflammation 
of the cord, or as the result of the affection known as poliomyelitis 
(idiopathic or toxic), in which the ganglionic cells alone are in- 
volved. The diagnosis of the traumatism must be made out by 
the history : an acute myelitis is readily recognizable by the nu- 
merous symptoms which attend it (see page 65), and which dwarf 
the mere wasting of the muscle and loss of power. A general 
neuritis producing palsy and trophic changes is almost invariably 
attended with violent pain and tenderness; and even in the rare 
cases in which no severe pain is felt, the nerve-trunks are from 
the first excessively tender. In poliomyelitis the nerve-trunks 
are never tender. For the further consideration of the symp- 
toms of multiple neuritis, see page 56. 

The difficulties which offer themselves in the diagnosis of 
idiopathic poliomyelitis are usually confined to the early stages 



TEOPHIC LESIONS. 239 

of the acute form, when it is liable to be mistaken for an acute 
constitutional disorder. Poliomyelitis of an acute or subacute 
type occurs especially during childhood, although it may happen 
at any age. Its tendency to attack early in life is probably due 
to the fact that at this time the trophic cells are in an habitual 
condition of intense functional activity and excitement, because 
they have not only to maintain nutrition, but also to direct de- 
velopment.* 

For the purposes of description it is necessary to recognize two 
types of poliomyelitis, — namely, the acute and the subacute, — 
although in nature these two types pass into each other by insen- 
sible gradations. In the most severe acute cases constitutional 
symptoms are often very violent and are apt to mask the char- 
acteristic local symptoms. 

Laborde considers acute poliomyelitis as consisting of four 
stages : in this he is followed by Grasset ; and if it be under- 
stood that these stages grade into one another and are arbitrarily 
created or separated for the purposes of description, the division 
is a good one. The first stage is that of attack; the second, 
that of more or less complete and generalized paralysis ; the 
third, that of remission and localization of the paralytic phe- 
nomena ; the fourth, the period of muscular atrophy and de- 
formity. 

During the first stage and in very severe cases the constitu- 
tional symptoms are most prominent. They consist of fever, 
disturbed cerebration, and convulsions. The fever is usually of 
short duration, lasting, it may be, only a few hours, sometimes 
a single day, but more rarely as long as one or even two weeks. 
It may be of a continuous type, but is very prone to be remittent, 
especially when it endures for any length of time. Even before 
the attack great nervous irritability, emotional excitement, and 
paroxysms of terror and other evidences of disturbed cerebration 



* Acute poliomyelitis as it occurs in adults has been considered by many 
writers as a distinct affection ; and even so clear and systematic an author as 
Grasset still devotes a separate chapter to its consideration. The acute spinal 
paralysis of adults is, however, without doubt the same disease as the essen- 
tial palsy of childhood, or infantile paralysis. The old names should be 
abandoned, and whether it occurs late or early in life the disease should 
be known as poliomyelitis. 



240 DIAGNOSTIC NEUROLOGY. 

are often present; and when the fever develops, confusion of 
ideas passes into delirium, and slight somnolency into profound 
coma. At the same time convulsive manifestations appear. 
These may be local, but are more usually wide-spread : when 
generalized, they may consist of twitchings or of frequently- 
repeated spasmodic contractions, or may rise to the severity of 
the most furious general convulsions, which are often accom- 
panied by vomiting, but are very rarely, if ever, fatal. It is 
possible, however, that some fatal obscure convulsive attacks in 
children really represent incipient poliomyelitis, the recognition 
of which may be impossible owing to the early death. 

So soon as the paralytic phenomena become prominent the 
patient may be considered to have entered upon the second stage: 
at this time the fever usually, but not always, abates. The 
paralysis may be general, attacking the trunk and neck and all 
the extremities, and if at the same time the loss of power be 
complete, the child is unable to move any portion of the body 
below the face. Generally, however, it will be found that a leg 
or an arm or some portion of the body is only partially affected. 
Even in cases of most complete paralysis the sphincters are not 
implicated, although urinary incontinence is not rare ; and in the 
severest cases there is no tendency to the formation of acute bed- 
sores. It is the exceptional case in which the whole body is 
paralyzed. As has just been described, paraplegia is more fre- 
quent than general paralysis ; hemiplegia and simple monoplegia 
are at this stage alike very rare. 

Trophic changes in the muscles can usually be detected by the 
sixth or seventh day, sometimes as early as the fifth, rarely not 
until the eighth or ninth. 

The first decisive evidence of such changes is loss of faradic 
contractility and the appearance of the reaction of degeneration. 
In those muscles which are to recover their power, trophic changes 
occur very slowly and only to a slight extent. It is a sufficiently 
accurate rule for the purposes of ordinary prognosis to say that those 
muscles in which the reaction of degeneration is pronounced at 
the end of the eighth day will in all probability never recover j 
their integrity, but that those which, although more or less com- 
pletely paralyzed, respond to the faradic current at such time will > 
probably regain their functional power. ; 



TROPHIC LESIOIS^S. 241 

The third stage of the disorder is that of remission and im- 
provement. The paralysis begins in certain parts of the body to 
improve slowly: if the improvement involves, equally^ or nearly 
equally, all the muscles, the prognosis becomes very favorable, as 
the case usually goes on to complete recovery. In the majority of 
instances, however, certain groups of muscles do not regain power 
along with the general system. Indeed, the reaction of degener- 
ation in these muscles may become more and more pronounced, 
and steadily advance, whilst electro-contractility in the other mus- 
cles is becoming normal. The paralysis usually ameliorates first 
in the neck and trunk, then in the arms, finally in the lower 
I extremities. In rare cases the legs improve before the arms. 
I Under such circumstances almost invariably many of the muscles 
i of the arms settle into a permanent paralysis. In the majority 
il of instances the final loss of power is confined to the lower ex- 
tremities, and in them only certain groups of muscles remain 
paralyzed. The groups which are least apt to escape are the 
! anterior and external muscles of the leg, and even more fre- 
\\ quently the abductor muscles of the foot, especially the peroneal 
i^ rauscles. The muscles of the foot itself are rarely permanently 
.' paralyzed ; the gastrocnemius occasionally. Of the muscles of 
the upper extremity the deltoid is the most likely to suffer. It 
is very exceptional for the muscles of the neck or of the trunk 
not to recover, although the erector spinse muscles do sometimes 
i atrophy. 

The fourth stage of acute poliomyelitis which is recognized by 
Laborde and Grasset is really not a part of the disease at all. It 
lis the state of paralysis that follows the disease; it is the per- 
manent condition into which the patient is thrown by the disease. 
The muscles are atrophied : in rare instances their wasting is 
masked by fatty deposits. If the patient has been attacked early 
m life, the bones are arrested in development, so that the limb 
remains not only much smaller but also much shorter than its 
fellows. That the ligaments also suifer trophic changes is indi- 
cated by the complete relaxation of the joints. 

The picture which has just been given applies to the acutest 

^form of poliomyelitis. In the greater proportion of cases which 

are met with, the onset is far more insidious. The febrile symp- 

itoms may be overlooked, on account of their brevity and their 

16 



242 DIAGNOSTIC NEUROLOGY. 

mildness; but it is probable that in many cases they are entirely i 
wanting. Certainly in the majority of the many cases that I [ 
have seen, no history of the fever could be obtained. Under i 
these circumstances the paralysis is usually not general or wide- ; 
spread; moreover, its development seems to be comparatively 
slow, so that not rarely at first only the gait of the child is j 
affected, but after some days the paralysis deepens into a com- | 
plete loss of power. It is probable that in these cases the original | 
attack is limited to a certain number of spinal cells, and is not 
sufficient to produce constitutional disturbance, such as fever, 
delirium, etc., and also that in the affected cells some days are 
required for the full development of the degenerative process. 

Arsenical Poisoning. — A set of symptoms closely resembling 
those of acute or subacute poliomyelitis are sometimes produced 
by metallic poisoning. It is probable that various metals are 
capable of causing these effects, but I have never seen them except 
as the result of arsenical or of lead poisoning. In arsenical poi- 
soning they are usually preceded by such acute and characteristic 
manifestations as to make the recognition of their nature very 
easy; but in one or two cases of saturnine disease that have 
come under my notice the poliomyelitic symptoms were not pre- 
ceded by any of the ordinary characteristic evidences of lead- 
poisoning. There must be a lesion either in the trophic centres 
or in the nerve-trunks, or more probably in each of these tissues. 
For an elaborate discussion of this question the reader is referred 
to my treatise on Therapeutics. 

In the cases of arsenical poisoning with poliomyelitic symptoms 
which have come under my care the muscular atrophy has been 
associated, at least in its earlier stages, with violent darting pains, 
much tenderness, and loss of sensibility,— symptoms all pointing 
to the presence of neuritis; the falling away of the muscles is 
rapid, requiring, however, some weeks for its full development, 
and is associated with the presence of true reaction of degenera- 
tion. Although all portions of the body may suffer, the distalj 
ends of the extremities are most prone to be attacked, and the( 
legs preferably to the arms. In an elaborate monograph (Paris,| 
1881) Imbert-Gourbeyre has shown that atrophic arsenical palsyi 
may take on a paraplegic or even a hemiplegic form, and ma^, 
also simulate a multiple paralysis, to which last variety of palsy) 



TROPHIC LESIONS. 243 

it may indeed be considered to belong. According to Imbert- 
Gourbeyre, ninety-seven per cent, of the cases recover. 

Lead-Poisoning'. — In my experience, when symptoms resem- 
bling those of acute poliomyelitis have resulted from lead-poison- 
ing, the upper extremities have been usually primarily attacked, 
the flexors and extensors both being attainted, and the alterations 
of the deltoid muscles following very rapidly upon those in the 
forearms. In several cases from the arms the paralysis has spread 
throughout the whole body, until, in the course of a few days, 
almost all the voluntary muscles have been involved, and in ex- 
treme cases the patient has at last become unable to do more than 
turn the head on the pillow. The affected muscles waste rapidly, 
offering the reaction of degeneration ; pain and disturbance of 
sensibility have been absent, so that the picture has very closely 
resembled that of ordinary infantile paralysis. The successive 
implication of all the muscles occurring in an adult is, however, 
sufficient to raise a suspicion of toxic origin, and in all my cases 
the blue line upon the gums revealed at once the nature of the 
affection. Undoubtedly, however, this saturnine atrophic palsy 
may exist without the blue line. Under these circumstances the 
diagnosis can be positively determined only by finding lead in the 
urine, A symptom which in severe cases separates the toxic from 
the idiopathic disorder is the involvement of the sphincters, which 
are never attacked in idiopathic poliomyelitis, but are very apt to 
be paralyzed in acute saturnine atrophy of the muscles. The di- 
; agnosis is a matter of great importance, because all my saturnine 
i cases have yielded to treatment.* 

Progressive Muscular Atrophy. — Chronic wasting, with loss 
; of power, of muscles occupying a more or less extensive territory 
! of the body, is usually due to the disease known as progressive 
j muscular atrophy, an affection which might be considered to repre- 
sent the slow form of acute poliomyelitis, and therefore be named 
chronic poliomyelitis. We have, however, no positive knowledge 
as to whether the lesion is essentially the same in the acute and 

* Although therapeutics are not at present under consideration, it is per- 
,! haps allowable to call attention to the extraordinary power over saturnine 
I palsy possessed by enormous doses of strychnine. Of course the iodide of 
^ potassium should be administered to aid in the elimination of the lead, but 
j never in the same prescription with the strychnine. 



244 DIAGNOSTIC NEUROLOGY. 

the chronic disorder. We know only that the lesion in each affec- 
tion occupies the same site, — namely, the spinal ganglionic cells. 
The difference is that in acute poliomyelitis or infantile paralysis 
large masses of cells are attacked simultaneously, while in the 
chronic progressive muscular atrophy individual cells are affected, 
one after the other. 

The onset of progressive muscular atrophy is always very slow 
and insidious. In most cases, before any marked change can be 
noted in the muscle, the sufferer perceives a loss of endurance, so 
that the part tires easily, or there may even be absolute loss of 
power for short exertion. Careful examination will now show, 
even if there be no sensible wasting, that the muscle is softer and 
more flaccid than normal. Sensibility is not impaired. 

A symptom which often precedes any marked change in the 
volume of the muscle is fibrillary contractions. The variation in 
the amount of the fibrillary contraction is indeed so excessive as 
to lead to the suspicion that possibly the diseased process which 
attacks the ganglionic cells is not always the same, so that two or 
more diseases are comprised in progressive muscular atrophy as at 
present recognized. 

In their mildest form the fibrillary contractions consist of slight 
irregular twitchings, occupying now this, now that portion of the 
belly of the muscle, and producing no effect except a corresponding 
movement of the skin over the contractions. The fibrillary con- 
tractions in their severest manifestations may amount to stormy 
peristaltic movements, hurrying through the muscle one after the 
other in immediate repetition. When the fibrillary contractions 
are very severe, the disease-process, at least in my experience, isj 
rapid, the wasting of the muscle notably increasing from day to| 
day under observation. In the slowest forms of the disease, in 
which many months or even years are required for much destruc- 
tion, the fibrillary contractions are usually sluggish. 

The loss of power takes the form of a multiple paralysis, — than 
is, groups of muscles more or less isolated are attacked in differH 
ent parts of the body. In the majority of cases the changes arq 
somewhat symmetrical. Thus, if one region of the hand be at-| 
tacked, the same region upon the other hand will be affectedJ 
This rule is not invariable, and even when the symmetry is de 
cided it may often be noted that not precisely the same muscles 



TEOPHIC LESIONS. 245 

are aflPected upon the opposite side of the body. Although loss 
of endurance or even partial paralysis may apparently precede the 
loss of muscular substance^ the loss of power is due to the loss of 
muscular substance, and not the loss of substance to the loss of 
power; or, perhaps more correctly, it may be considered that both 
symptoms have a common basis : i,e,, when a spinal ganglionic cell 
is attacked, the fibres of the muscles individually supplied by it 
suffer simultaneously in their nutrition and in their motor func- 
tions. Usually the hands are the first portions of the body to be 
affected, the symptoms frequently being much more severe in the 
right hand. 

According to Eulenberg, the interosseous muscles are almost in- 
variably the first to be attacked, whilst Roberts, Wachsmuth, and 
Friedreich state that the the ball of the thumb is usually impli- 
cated before the interosseous muscles. The first external inter- 
osseous is said to be the first to feel the influence of the disease, 
whilst the opponens and the adductor pollicis are more apt to 
suffer than the extensors, the abductors, and the flexors of the 
thumb. In the few cases in which I have had an opportunity to 
see the disease in its earliest stage the interosseous muscles were the 
first affected. The wasting of the muscles of the hand is usually 
readily perceived by the flattening of the thenar eminence and by 
the falling-in of the interosseous spaces. The diminished power 
of the interosseous muscles can usually be detected by noticing 
that when the patient attempts to abduct the index finger he sep- 
arates it vrith less vigor from the middle finger than normally. 
When only one hand is attacked, the contrast of movement is 
often decided. Instead of attacking the hand, progressive mus- 
cular atrophy may first make itself felt in other portions of the 
body, and especially is this true of the deltoid muscle; but it is 

! stated that the pectoralis major and the serratus magnus, or even 

I the lumbar muscles, may have to bear the onset. The upper 
extremities, the neck, and the trunk are certainly much more 

I frequently affected than are the legs ; nevertheless, the latter do 

< not always escape. 

Owing to the loss of power in certain muscles and to the ten- 
dency to contractures in their antagonists, the sufferers from pro- 
gressive muscular atrophy are prone to assume peculiar positions 

, or to have extraordinary deformities. In a patient under my own 



246 DIAGNOSTIC NEUROLOGY. 

care, the loss of power in the muscles of the neck was so great 
that the head perpetually fell forward, the chin almost resting 
upon the breast. In this case the upper arms were much more 
prominently affected than were the forearms, so that whilst the 
man still preserved a good grip the arms were perfectly flaccid and 
helpless, owing to the complete paralysis of the deltoid, biceps, and 
triceps. 

The most characteristic of the deformities is that which is 
known as the clawed hand {main en griffe, Klauenhand), and which 
is produced by the permanent flexion of the last two phalanges of 
the fingers which are extended at the metacarpal joint. As was 
shown by Duchenne, this deformity is the result of atrophy of the 
internal and external interosseous muscles with the preservation 
of power by the extensors and flexors of the fingers. It must be 
remembered that this deformity is really pathognomonic of paraly- 
sis of the interosseous muscles, and is characteristic of progress- 
ive muscular atrophy only for the reason that loss of power of the 
interosseous muscle is rare from other causes. If, however, from 
local disease of the nerves the interosseous muscles are paralyzed, 
the clawed hand is developed. If only one hand is clawed, the 
suspicion of local disease should be at once aroused. When the 
muscles about the shoulder-joint are paralyzed, either by sharing 
in the trophic changes or by the loss of the support of the muscles, 
the ligaments suffer elongation and the joints become very loose, 
so that a subluxation readily occurs. 

A very important symptom in the diagnosis of progressive 
muscular atrophy is the preservation of the electro-muscular con- 
tractility. This at first sight may appear to be at variance with 
the theory that the lesion in the muscle is the result of destruc- 
tion of the trophic cells in the anterior cornua of the spinal cord. 
The explanation of the paradox, however, is simple. The de- 
struction of the ganglionic cells progressively involves individual 
cells one after the other, and, consequently, the trophic destruc- 
tion of the muscles compromises individual bundles of fibres one 
after the other. The muscle, therefore, loses power, not en masse, 
but fibre by fibre, and that portion of the muscle which retains its ( 
functional activity preserves its normal electrical reactions. 

I have never seen the reaction of degeneration demonstrated u/ 
progressive muscular atrophy, although it is affirmed by Eulen-i 



TROPHIC LESIONS. 247 

berg that in the later period of the disease there may be 
qualitative alterations in the muscular reaction, — i.e., an in- 
creased reaction under anodic closure and less commonly under 
eathodic opening. Eulenberg states that he has never seen in 
progressive muscular atrophy extreme degrees of qualitative devi- 
ation from the normal reaction. The so-called diplegic contrac- 
tions which Remak has affirmed to be of frequent occurrence 
in progressive muscular atrophy are rarely to be demonstrated. 
The following paragraph from Eulenberg explains the method of 
developing these contractions : 

^' Remak found that the contractions could be produced in the 
atrophied muscles of the arm when the positive electrode was 
placed in an ' irritable zone/ which extends from the first to the 
fifth cervical vertebra, or, still better, in the carotid fossa, or the 

I triangle between the lower jaw and the external ear, while the 
negative was put below the fifth cervical vertebra. The contrac- 

: tions were always on the side opposite to the anode, but when 
the electrodes were applied in the median line they occurred on 

' both sides. If the current was very weak they were limited to 
the muscles most severely affected. Remak regarded these as 
reflex contractions originating from the superior cervical gan- 
glion of the sympathetic, and especially as the patient perceived a 

I sensation behind the ball of the eye when the current was closed.^^ 

In some cases of progressive muscular atrophy the response to 
the faradic current appears more active than normal. This may 
, in some instances be due to wasting of the muscle, enabling the 
( current more rapidly and thoroughly to reach the portion of the 
muscle left ; but it would seem that there is sometimes a height- 
ened irritability of the muscular fibres which have not suffered 
: degeneration, and I have thought this was especially present when 
the fibrillary contractions were very severe. Again, in those cases 

II in which the muscle as it wastes is replaced by fatty tissue, the 
- electro-muscular contractility may appear to be below normal on 
I account of the resistance which the fatty matter offers to the 
, faradic current. 

I The course of a true idiopathic progressive muscular atrophy is 

II usually steadily progressive until the final destruction of all the 
/ affected muscles. 

G-losso-Labial Palsy. — In 1861, Duchenne described, under 



248 DIAGNOSTIC NEUROLOGY. 

the name of Glosso-Labial Paralysis^ a slowly progressive loss 
of power in the tongue^ lips^ palate^ and muscles of the throat, 
which is only a form of progressive muscular atrophy. The 
medulla oblongata is simply the upper portion of the spinal cord, 
and when the nuclei within it undergo degeneration the muscles 
tributary to it suffer changes precisely like those produced by 
similar degenerations of the nuclei of the lower spinal cord. The 
degeneration of the nuclei of the medulla may accompany that 
of other spinal ganglia, when the patient suffers from progressive 
muscular atrophy and glosso-labial paralysis so called, or the 
bulbar nuclei may alone suffer when a pure glosso-labial palsy 
results. The symptoms in glosso-labial paralysis vary in accord- 
ance with the varying of the degenerations in the medulla. Fre- 
quently the paralysis of the tongue is the first to appear, but the 
tremulousness and loss of the labial articulation may precede the 
lingual affection. 

The course of glosso-labial paralysis is entirely parallel with 
tliat of other forms of progressive muscular atrophy. Its symp- 
toms are peculiar, on account of the connection of the affected 
muscles with pronunciation, and its ending comparatively rapid, 
because deglutition is interfered with. There are, however, the 
same progressive weakness, the same slow wasting, and the same 
fibrillary contractions in the affected muscles, with persistent re- 
tention of electro-contractility, as in other forms of progressive 
atrophy. The tongue is protruded more and more slowly and 
imperfectly, and becomes more and more tremulous. Owing to 
loss of control over it, the pronunciation of the lingual vowels and 
of the dental consonants is imperfect. The weakness of the lips 
shows itself by failure in articulation of the labial consonants, by 
the inability to whistle, by tremulousness, and, finally, by the loss 
of the power to contain the saliva in the mouth, which dribbles | 
constantly. As the disease is almost always symmetrical, the j 
mouth is not drawn to one side, but the wasting of the parts about ' 
it may be sufficient to make the orifice appear much larger than I 
normal and to confuse the naso-labial folds. Sometimes the lips t 
during laughter separate themselves but are incapable of sponta- 1 
neously returning to their natural position, so that the patient is i 
forced to replace them with his fingers. If the palate is markedly 
affected, the voice becomes nasal. Deglutition may be affected I 



TROPHIC LESIONS. 249 

early or late in the disorder, and, as the loss of power of swallow- 
ing is paralytic, liquids are swallowed with much difficulty, and 
are apt to be returned through the nose. In some cases the larynx 
is attacked, and the voice becomes almost inaudible, without, how- 
ever, being completely lost. In those cases in which the nuclei 
of the respiratory nerves are implicated the respiratory muscles 
undergo w^asting and the respiration becomes much affected. 
Any attempt at violent movement, or, later in the disease, even 
ordinary walking, may cause a severe attack of dyspnoea. At last 
these cyanotic crises come on spontaneously in furious paroxysms, 
which may occur either by day or by night. A peculiar symp- 
tom which especially characterizes this dyspnoea is a sensation 
of excessive fulness of the chest, which is probably produced by 
the feebleness of the muscles preventing them from thoroughly 
emptying the lungs. In some cases the nuclei of the cardiac 
nerves appear to be attacked, and cardiac crises become violent 
and alarming. These are especially apt to be present in those 
cases in which the respiration is affected, but may occur without 
the respiratory muscles suffering. The pulse in the cardiac crises 
is very feeble, irregular, intermittent, and at last may be imper- 
ceptible. The face is exceedingly pale and anxious, and there is 
habitually an intense terror, w^ith a sense of impending death. 
The ocular muscles may be affected in glosso-labial paralysis, 
although they usually escape. 

The '^ophthalmoplegia externa^^ of Hutchinson is in some cases 
the expression of a progressive muscular atrophy. (See chapter 
on Special Senses.) 

Although glosso-labial paralysis occurs with sufficient frequency 
to be recognized as a clinical group, it must be remembered that 
all sorts of irregularities exist in the method of attack, that certain 
muscles about the face may be affected simultaneously with distant 
muscles in the body, and that the disease is only one of the many 
forms of progressive muscular atrophy. 

Progressive Facial Hemiatrophy. — Atrophy of one side of 
the face requires mention here, because it may possibly be a 
trophic lesion due to some central disease allied to poliomyelitis, 
although at present this cannot be considered as established. The 
f disease usually appears first as a whitish spot in the skin, which 
soon becomes brownish. Sometimes there are several of these 



250 DIAGNOSTIC NEUHOLOGY. 

spots, which finally coalesce. In a little while the skin becomes 
thinner, so that a depression is produced. As the change widens, 
the folds of the skin fade, and the surface grows smooth and 
parchment-like. Then the subcutaneous cellular tissue atrophies. 
The muscular tissue yields slowly. The bones, and even the car- 
tilages, especially of the nose, finally waste. The teeth may fall 
out ; and the tongue and palate have, in some cases, participated 
in the changes. The hair becomes white or is shed. 

In scleroderma and leprosy alterations of the nerve-trunks 
have been found, and the lesions of both affections are by some 
writers considered to be trophic : at present this, however, seems 
scarcely probable. 

TROPHIC CHANGES IN THE NERVOUS SYSTEM. 

The conducting nerve-fibres, both in the brain and in the spinal 
cord, and in the nerves themselves, appear to have their nutrition 
regulated by certain ganglionic cells with which they are con- 
nected, so that when isolated from such cells they undergo degen- 
eration. These trophic changes in the nervous system are usually 
so hidden from any possible external examination that they can 
be known during life only by their secondary efiects, of which 
muscular contracture is the only one definitely established. These 
contractures have already been suflSciently discussed (see page 167), 
and any further remarks upon the matter of trophic alterations of 
the nervous system may seem out of place in a work upon symp- 
tomatology. Nevertheless, I shall point out, in a few words, the 
laws which govern the trophic changes of nerve-fibres, and the 
directions in which such changes travel. 

The trophic cells which dominate the fibres of the pyramidal 
fasciculi are situated in the cerebral cortex, so that when the 
pyramidal fasciculus is broken anywhere, either in the brain. In 
the peduncles, in the medulla oblongata, or in the spinal cord, 
degeneration always begins upon the lower or distal side of 
the injury, and travels downward until it reaches the ganglionic 
cells in the spinal cord. These cells are new trophic centres 
governing the motor nerves. We have no knowledge that the 
descending degeneration ever passes over from the fibres of the 
pyramidal tract to the trophic centres in the cord. Hence it is 
that in cerebral palsies the muscles preserve their integrity for 



TROPHIC LESIONS. 251 

such a length of time. . Whenever the motor fibres passing from 
the ganglionic spinal cells outward are injured, whether such 
injury be situated in the cord, in the nerve-root, or in the trunk, 
degeneration always begins in the lower or peripheral segment 
of the nerve, and travels downward until the peripheral filaments 
of the nerve are involved. In other words, in the motor system 
the trophic influence rises from higher nerve-centres, and degen- 
eration therefore travels downward and outward. 

In the sensory system the trophic influence originates in the 
peripheral or lower ganglionic masses, so that the course of sec- 
ondary degeneration is from below upward. Thus, as was origi- 
nally discovered by Waller, if the nerve-roots are divided above 
the ganglia of the posterior roots, whilst the motor root degener- 
ates below the section, the sensory root degenerates above the 
section. Again, if the spinal cord be divided, in the animal 
by the knife, or in man by a disease (such as the transverse 
myelitis which often accompanies Pott's disease), below the 
point of section the antero-lateral columns which contain the 
descending motor fibres of the pyramidal tract undergo degen- 
eration, which progresses downward. The descending degen- 
eration travels more rapidly along the lateral columns, so that 
at a certain height in the cord it can be noted that they have 
undergone change, whilst the anterior fibres are as yet intact. 
Above the point of section the antero-lateral columns remain 
normal, but the posterior columns are altered through their 
whole extent. The lesion travels more rapidly along that band 
of the fibres which lies next to the posterior fissure and is known 
as the columns of Goll, so that at a certain height these fibres 
are diseased, whilst the posterior root-zone is unaffected. When 
the original lesion is situated in the dorsal region, the ascending 
degeneration is not confined to the posterior columns, but also 
passes up along a fine band situated in the posterior external 
portion of the lateral columns, or the tract to which has been 
given the name of direct cerebellar fasciculus. 

In cases of inflammations of nerves the neuritis frequently 
travels upward along the trunk. There is, however, no reason 
for supposing that trophic influence has anything to do with this 
progression. It is simply a propagation of the inflammation by 
continuity, in accordance with a well-known general law. 



CHAPTER VI. 

SENSORY PARALYSIS. 

In the present volume the term anaesthesia is used as equivalent 
to paralysis of sensation. Like motor palsy, it may be complete 
or incomplete ; but, since sensation is, unlike motion, a complex 
function, sensory palsies vary not only in degree but also in kind 
and in position. An anaesthesia may affect the surface of the 
body, when it is spoken of as cutaneous, or it may be located in 
mucous membranes or in muscles or in internal viscera, or, finally, 
it may be situated in the region of special sense. Special sense 
anaesthesias will be discussed in the cliapter on the Special Senses, 
and concerning them, therefore, nothing further will be said in 
this place. The function of sensation is not highly developed in 
mucous membranes, and we are not able to distinguish the varie- 
ties of anaesthesia in these positions that are seen upon the skin. 

Cutaneous sensations may be divided for clinical purposes into 
two groups : firstj those which are known as general or common 
sensations, as pain, itching, titillation, sensual pleasure, and the 
feelings arising from electrical excitation ; second, special sensa- 
tions of pressure, of temperature, and of locality.* 

In practical medicine cases arise in which special sensations are 
paralyzed, although common sensibility is preserved. It is there- 
fore necessary to employ various tests for the recognition of the 
exact condition of the part to be studied. It must be remembered 
that the responses which we receive from these tests are made by 
the patients, and may be misleading, especially in hysteria and 
malingering. In the examination of such cases subjective symp- 
toms cannot be relied upon, and the judgment must be formed 
from the objective symptoms which are beyond the control of 
the patient and are seen by the physician himself. 

"^ In separating the so-called sense of locality from common sensation I have 
followed custom, but have never been able to convince mj^self that the separa- 
tion is correct. It has always seemed to me that the power of separating the 
points of the aesthesiometer depends upon the condition of general sensibility. 
252 



SENSORY PARALYSIS. 253 

Modes of Testing Sensation, — Common sensibility may be tested 
with any small sharp instrument^ as a needle or a knife-point, or 
by pinching, or by means of the electric brush. The latter instru- 
ment is especially valuable, because the peripheral nerve-filaments 
may be intensely irritated by it without causing any structural or 
permanent change. In some cases of disease, although sensation 
is not completely abolished, its pathway is so blocked up that a 
much longer time is required than normal for the perception of 
the peripheral sensory impulse by the brain. In extreme cases 
this retardation of sensation is perceptible by the watch. The 
detection of minor degrees of it requires very delicate appara- 
tus, and much physical training, and is of no avail in practical 
medicine. 

The instrument used for testing the sense of locality is known 
as the cesthesiometer. It consists in its simplest form of a pair 
of ordinary compasses with blunted points. In its more refined 
forms it is composed of a pair of points, one of which slides upon 
a bar, so that the distance between the points when separated is 
known; or the compasses themselves may be furnished with a 
graduated scale. When the points of the sesthesiometer are 
brought into contact with the surface of the body they are felt as 
two points or as a single point, according as they are more or less 
widely separated and as the skin is more or less sensitive. The 
sensibility varies greatly in different parts of the skin, but, ac- 
cording to the results obtained by Weber and Valentin, the dis- 
tance at which the points of the compass must be separated in 
order to be felt as two points is to some extent constant in the 
same region of the body in different individuals. The following 
may be taken as the normal scale from which any marked devia- 
tions must be regarded as pathological : the top of the tongue, 
1.18 mm. ; the end of the fingers, 2.25 mm. ; the side of the first 
phalanx, 16 mm.; the back of the hand, 31 mm.; the upper arm 
and thigh, 37 mm. The smallest required distance is oftener less 
in the transverse than in the longitudinal direction of the limbs. 

Although a certain degree of constancy does exist in different 
individuals in regard to cutaneous sensitiveness, yet the differences 
are so wide that, when it can be done, it is preferable to compare 
the affected part with the opposite side of the body rather than 
with any theoretic formula. Care must be taken in applying the 



254 DIAGNOSTIC NEUBOLOGY. 

compasses to see that their two points are brought simultaneously 
in contact with the skin, otherwise the sense of double contact may- 
be produced by the alterations of time. Also the compass-points 
must be kept quiet and a uniformity of pressure be maintained. 
When the hands are the seat of the supposed loss of sensation, 
the use of the sesthesiometer may well be supplemented by de- 
termining whether the patient with the eyes shut can tell the 
difference between a rough and a smooth object. 

The sense of pressure is tested by laying the hand, foot, etc., 
upon a firm, hard surface, like that of a table, and placing grad- 
uated weights upon it. Several forms of apparatus have been in- 
vented for the purpose of testing the pressure-sense, but none of 
them have any material advantage over the simpler plan. In 
order to avoid bringing into play the muscular sense, it is essential 
that the part on which the weights are laid be thoroughly sup- 
ported. A very convenient method is to fill a series of ordinary 
shot-gun cartridge-shells with shot and wadding so as to form a 
regular series of weights which resemble one another exactly to 
the eye. 

The power of recognizing the differences of temperature may be 
tested by the alternate application of hot and cooler bodies. More 
or less complicated instruments have been constructed, under the 
name of thermo-cesthesiometers ; but vials of water of different 
temperatures are sufficient for practical puposes. The temper- 
ature-range of most accurate sensation lies between 27° and 30° 
C, then between 33° and 39° C, and lastly between 14° and 27° 
C. The variations above or below these limits produce simply sen- 
sations of pain. According to the experiments of Nothnagel, the 
smallest perceptible differences of temperature are the following: 
on the breast, 0.4° C. ; on the back, 0.9° C. ; on the back of the 
hand, 0.3° C. ; palm of the hand, 0.4° C. ; arm, 0.2° C. ; back 
of the foot, 0.4° C. ; lower extremities, from 0.5° C. to 0.6° C; 
the cheek, 0.4° C. to 0.2° C. ; the temples, 0.4° C. to 0.3° C. In 
practice few normal individuals will recognize, I believe, differ- 
ences of temperature so small as those mentioned. | 

I 

For the purposes of clinical study, anaesthesia of the surface) 
of the body is best separated from anaesthesia of the mucou^?^ 
membranes and of other internal tissues. For these respective) 



SEXSORY PARALYSIS. 255 

anaesthesias the names Visceral and Cutaneous may be used as 
convenient^ although not absolutely correct. 

VISCERAL ANESTHESIAS. 

The important visceral anaesthesias met with in practice are 
those of the throaty rectum, bladder, and vagina. It is probable 
that certain obscure aflPections of the internal viscera may be con- 
nected with paralysis of their sensory apparatus, but of such dis- 
eases or such affections we have at present no definite knowledge. 
Like cutaneous anaesthesia, these deeper-seated losses of sensation 
may be either of hysterical or of organic origin. The distinctions 
between hysterical and organic anaesthesia will be fully developed 
in the section on Cutaneous Anaesthesia. For the present, I shall 
merely point out the symptoms which are produced by anaesthesia 
of deep-seated parts, and their usual etiological relations. 

Anaesthesia of Throat. — Anaesthesia limited to the throat is 
a rare condition, which may occur after diphtheria, or in con- 
sequence of disease of the nerve-trunks, or may be seen in other 
limited organic affections of the nervous system. In combina- 
tion with other symptoms, buccal and pharyngeal anaesthesia is 
frequently present in general anaesthesia or hemianaesthesia of the 
hysterical or organic type. It is especially apt to be pronounced 
in hysterical cases. M. Chairou (jStudes cliniques sur la Parcdysie, 
1870) has, indeed, insisted upon the insensibility of the pharynx 
and of the epiglottis as almost pathognomonic of hysteria. In 
many cases anaesthesia of the throat produces no distinct symp- 
toms, and is discovered only when the parts are touched. The 
lack of symptoms is evidently due to the fact that the loss of 
sensitiveness is usually either confined to one side of the throat 
or is not complete. A complete anaesthesia of the pharynx and 
upper oesophagus would suspend the reflex movements of swallow- 
ing: it probably enters largely into the diflSculty of deglutition 
which sometimes follows diphtheria. 

Rectal Anaesthesia. — Rectal anaesthesia may be due to hys- 
teria, to wide-spread degenerations of the brain-cortex, to myelitis, 
or to locomotor ataxia : when it is complete the desire for defecation 
does not exist, and the faeces may be retained in the rectum until 
there is, as in the incontinence of urinary retention, an overflow, 



256 DIAGNOSTIC NEUROLOGY. 

which is manifested by a perpetual discharge of small masses of 
faeces. If the faeces are hard from lack of secretion, the rectum 
becomes distended with an enormous stony mass. If the dis- 
charges are moderately soft, the physician is usually informed that 
the patient suifers from diarrhoea. In some of these cases not 
only the rectum but also the anus and its surroundings are dis- 
tinctly anaesthetic. Sensibility may, however, be perfectly pre- 
served in the skin and mucous membranes upon the verge of the 
anus, although no amount of stretching of the sphincter or intes- 
tine hurts the patient (Mitchell). An anaesthesia of one side of 
the rectum probably often occurs in cases of organic, and perhaps • 
also of hysterical, hemianaesthesia, but is not discovered because 
the sensitive side of the rectum is sufficiently alive to perform all I 
the necessary functions. 

Vaginal Anaesthesia. — Vaginal anaesthesia is a not rare hys- 
terical disorder. It is usually associated with a loss of sensibility 
in all the organs of generation, and complete loss of sexual desire, 
sometimes even absolute repugnance to sexual intercourse. Ex- 
cept in married women, it generally escapes notice. 

Bladder Anaesthesia. — Anaesthesia of the bladder gives rise 
to retention of urine as its chief symptom. It is especially in this 
form of urinary retention that a perpetual overflow — i,e,, inconti- 
nence — is liable to mislead the unwary into believing that the' 
bladder is sufficiently emptied. This danger is much increased 
by the lack of desire for urination, a symptom which is almost! 
diagnostic of the condition. Sensory paralysis of the bladder' 
occurs in hysteria, and is an occasional symptom of locomotor | 
ataxia. When it is due to posterior sclerosis of the cord it isi 
associated with genito-urinary pain-crises, which often serve to I 
distinguish it from the hysterical disorder. 

CUTANEOUS ANESTHESIA. 

Cutaneous anaesthesia* is in its location parallel with motorl 
palsy. It may affect the whole or the greater portion of the sur-' 
face of the body, constituting a general anaesthesia. It may be) 

•^ Hereafter in this book the term anaesthesia will be used as signifying 
cutaneous anaesthesia. 



SENSORY PARALYSIS. 257 

limited to one lateral half of the body, constituting the so-called 
hemianaesthesia. It may be confined to one extremity, when it 
is known as monoansesthesia ; and precisely as two monoplegias 
may coexist, so we may have a double monoanaesthesia, which 
may simulate hemianaesthesia, or, existing upon the opposite sides 
of the body, may produce a crossed sensory paralysis. Anaes- 
thesia may affect the lower half of the person, constituting a par- 
anaesthesia. It may affect only the territory under the domination 
of one nerve, or of one group of nerves, constituting a local anaes- 
thesia. 

For the purposes of study, cases of anaesthesia are best arranged 
in certain etiological groups, — namely, hysterical anaesthesia, psy- 
chic anaesthesia, organic anaesthesia, and toxaemic anaesthesia. The 
last two groups might without violence to nature be considered 
together, but the changes in the sensory nerves which occur in tox- 
'^aemic anaesthesia may not be sufficiently gross to be recognized by 
• the microscope ; moreover, the distinction between functional and 
organic diseases is an arbitrary one, and it is clinically more con- 
venient to study toxaemic anesthesias as a single group. 

Psychic anaesthesia — i.e., anaesthesia connected with psychosis — 
is no doubt dependent upon changes in the brain -cortex, which 
may or may not be sufficiently gross to be recognized, but, for 
'ireasons similar to those just adduced, I prefer to consider it as 
^'separate from organic anaesthesia. There is no positive relation 
between the etiology of an anaesthesia and its location. An hys- 
terical anaesthesia or an organic anaesthesia may take upon itself 
'|any one of the forms based upon the distribution of the palsy 
and constitute a monoanaesthesia or hemianaesthesia, etc., as the 
case may be. A crossed anaesthesia is, however, very rarely or- 
ganic, while a toxaemic anaesthesia usually is wide-spread in its 
distribution, although it may affect local areas which are more or 
jless numerous and more or less widely separated. 

- HYSTERICAL ANESTHESIA. 

Hysterical anaesthesia may be confined to a limited area, but 
is usually wide-spread : frequently it is strictly confined for the 
xime being to one-half of the body, either as a hemianaesthesia or 
^ a paranaesthesia ; not rarely it is irregular in its distribution, 
land it may exist upon opposite sides of the body. It especially 

17 



258 DIAGNOSTIC NEUROLOGY. 

affects the skin, but may make itself manifest in the deepest 
structures. It may be complete or incompl-ete. In a case reported 
by Briquet, a young girl had complete sensory paralysis of the 
skin and the muscles ; the hearing and vision of the left side were 
gone, and the senses of taste and smell entirely lost. Her insensi- 
bility was so complete that, after the eyes were bandaged, she had 
no perception of being lifted from the carriage to the bed. In 
many cases of hysterical ansesthesia the loss of sensibility is limited 
to small portions of the trunk, and in a case reported by Leroy it 
was confined to the conjunctiva and cornea of one eye. M. Four- 
nier has reported as occurring in nervous syphilis a localized 
anaesthesia of the skin, of the hands, and of the mammary region, 
which was almost certainly of hysterical origin. Not rarely the ! 
hysterical anaesthesia occupies the lower half, or the lower two- ■ 
thirds, or a greater or less fractional part, of the body. It is rare I 
in the face, but certainly does occur there : it is exceedingly un- 
common for it to implicate the whole face. 

Hysterical anaesthesia may be complete or incomplete. In 
especially occurs thermo-ancesthesia, — i.e., that condition in which 
the power of distinguishing between heat and cold is lost, al- 
though general sensibility is preserved. Analgesia, or loss of the 
pain-sense, existing by itself is also almost invariably hysterical. 
Thermo-ansesthesia and analgesia may coexist in hysterical subjects,; 
but in the majority of cases the paralysis affects all the sensory 
functions. 

A phenomenon which is usually present in marked hystericall 
anaesthesia is the so-called ischcemia. In this condition thei 
surface is pale, and the prick of a needle or even an extensive 
superficial incised wound does not produce bleeding. Ansesthetio 
ischaemia appears to be specially pronounced in the violent epi- 
demic forms of hysteria, such as occurred in the convulsionnaires 
of the Middle Ages: hence the miracle that superficial woundsi 
were not followed by loss of blood. 

When, under the influence of local applications of metals, 
mustard plasters, or other active or indifferent substances (see pag€j 
260), sensation returns temporarily in a case of hysterical hemi-j 
anaesthesia, the ischaemia disappears and the needle-prick bleedsl 
Ischaemia has been held to be characteristic of hysterical heatff 
anaesthesia, but it has been observed by Dr. S. Weir Mitchell iij 



SENSORY PARALYSIS. 259 

cerebral hemiansesthesiaj and also in the complete loss of sensation 
which follows nerve-section. Thus, in a case in which the sciatic 
and crural nerves had been divided, repeated punctures with a 
very large needle were not followed by any blood : as the needle 
was withdrawn, a small snow-white ring, slightly raised, formed 
around the orifice and seemed to close it. 

Hysterical Hemiansesthesia. — Of the varieties of hysterical 
anaesthesia, hemiansesthesia is the most important, because of its 
frequency and of its close simulation of the organic affection. 
In its full extent it occupies one side of the body, and affects 
the special senses, causing deafness, loss of smell and of taste, 
and disturbances of vision. The latter may take the form of 
more or less complete amblyopia, but usually there is a concentric 
narrowing of the field of vision and a peculiar loss of color-sense, 
to which the name of achromatopsia has been given by Galezow- 
ski. In some cases the power of seeing the colors is entirely lost, 
so that all objects appear of a uniform sepia-tint. When the 
achromatopsia is not complete, the colors disappear in a constant 
order. The first color that an hysterical person ceases to see is 
violet ; usually, but not always, blue is lost before red, the inter- 
mediate tints fading out in regular succession. The loss of sensi- 
bility in hysterical hemiansesthesia is distinctly limited by a line 
drawn through the centre of the body. 

3IetaUotherapy. — In 1849, Dr. Burk discovered that in hysteri- 
cal anaesthesia it was possible, by the application of metals to the 
surface of the body, to recall sensibility, and in 1851 he presented 
an inaugural thesis upon the subject to the Faculty of Paris. It 
was not, however, until 1876 that he succeeded in attracting the 
I general professional attention of France to the matter. In that 
> year, in answer to his importunities, the Soci6t6 de Biologic of 
Paris appointed a commission to examine into the accuracy of 
j his alleged facts. The report of this commission (Paris, 1879) 
, confirmed the statements of Dr. Burk, and also extended our 
I knowledge of the subject. It was found that different individuals 
\ have different relations with metallic substances, some cases being 
affected by zinc, others by iron, others by gold, copper, etc. 
J In exceptional instances the hysterical person has relations with 
r two or even more metals. When a small disk of the appro- 
U priate metal is bound over the anaesthetic surface of an hysterical 



1 f 



260 DIAGNOSTIC NEUROLOGY. 



subject, after from ten to twenty minutes a sensation of warmth 
is developed beneath the disk, and a distinct reddish color appears. 
At this time the prick of a needle is distinctly felt, even pain- 
fully so, not only at the spot over which the plate has been ap- 
plied, but also in a more or less extended zone around it. In 
some cases the sensibility returns only in the immediate vicinity 
of the application ; in others the whole arm, or more rarely the 
whole side of the body, becomes sensitive. With the return of 
sensitiveness there is a disappearance of the ischsemia, and if 
motor palsy has existed there is also an increase of the motor 
power as measured by the dynamometer. In most cases of hys- 
terical anaesthesia there is a distinct coldness of the surface, or 
indeed of the whole arm, and with the disappearance of the 
palsy of sensation and of motion there is an increase in the 
temperature. Thus, in a case of right-sided hysterical anaesthesia 
and amyosthenia, the thermometer held in the right hand stood at 
36° C, in the left at 34.5° C. (Dr. Dumontpallier, La Iletallo- 
scopie, Paris, 1880), but after the application of the metal the tem- 
perature of the left hand was higher than that of the right. In 
many instances not only is the sensibility of the skin restored, 
but at the same time the special senses gradually become nearly 
normal, although in other cases it is necessary in order to affect 
the special senses that the metallic plates should be in the neigh- 
borhood of the orbit or in the temporal region. When achro- 
matopsia is relieved, blue is usually the first color to return, or 
more rarely red. Some minutes after this, yellow is perceived, 
then green, and at last violet (Dr. Aigre, La lletalloscopie, Paris, 
1879, p. 23). As seems to have been first discovered by M. 
Gell6, at the time of the disappearance of the anaesthesia under 
the influence of the metal the loss of sensibility appears in a 
corresponding position upon the unparalyzed side, and is accom- 
panied by a fall of the local temperature. In a few cases severe 
pains have developed during the application of the metals. Ac- 
cording to the experience of the French commission, which seems i 
to be identical with that of subsequent observers, the effect of the ' 
application is usually in hysteria at first temporary, and lasts from 
a few minutes to some hours. 

Dr. Burk, in his communication to the Soci6t6 de BioIogi€{| 
stated that if the metal which had been found temporarily toll 



SENSORY PARALYSIS. 261 

affect sensation in a person suffering from hysterical anaesthesia 
were given to such patient in continuous doses, all symptoms of 
hysteria would after a time permanently disappear. The com- 
mission confirmed, in a measure, this statement : in sundry cases 
they found under such administration that menstruation became 
regular, digestion improved, and the muscular force and sensi- 
bility returned. They further, however, made the extraordinary 
discovery that if a piece of the metal were bound down on the 
skin of the person who had recovered, a return both of anaesthesia 
and of motor palsy took place in from twenty to forty minutes. 

It having been suggested that the metal upon the skin acts 
by induction of feeble galvanic currents, the French commission 
found that the application of most metals to the surface of the 
human body gives rise to an electric current sufficiently powerful 
to be measured, that these currents vary in power with different 
metals, and that electrical currents of power equal to that of those 
produced by the appropriate metals applied to the anaesthetic sur- 
face brought about a return of sensibility. The observations of 
M. Luys showed that the application of the appropriate metals 
was also able to reduce hysterical hypersesthesia to the norm. 

That the phenomena of the so-called metallo-therapy as I have 

summarized them may frequently be obtained, in more or less 

completeness, is shown by the confirmation of the report of the 

French commission not only by a number of French observers, 

but also in England by Dr. A. Hughes Bennett (Brain, vol. i. 

part 3; Brit Med. Joitrn,, Nov. 25, 1878), in Italy by Buccola 

' and Sepilli (Loud. Med. Record, vol. ix.), and in Germany by 

Dr. F. Gratz (ibid.) and various other observers. It is, however, 

; certain that, at least in this country, they are exceptional. In 

an elaborate series of observations made in the wards of the 

I Philadelphia Hospital by my colleague. Dr. C. K. Mills, the 

I transfer of sensibility was obtained in only a very few cases, 

whilst Dr. S. Weir Mitchell affirms as the result of his great ex- 

j perience that neither he nor any of his assistants have ever been 

t able to bring about anaesthesia of the sound side, although they 

« have very frequently obtained temporary returns of sensibility 

by the application of various substances, especially by mustard 

r plasters, and even more pronouncedly by freezing the skin with 

I rhigolene. It was at first believed that the production of sensi- 



262 DIAGNOSTIC NEUROLOGY. 

bility by sesthesiogenetic agents is proof of the hysterical nature 
of an anaesthesia ; but in the course of his early observations upon 
the subject M. Charcot found that even in organic hemianaesthesia 
the application of the plates of metal was followed in twenty or 
thirty minutes by a return of the normal sensibility and of the 
special senses. These observations have been confirmed by several 
French observers. 

It is also asserted that if powerful magnets be used instead of 
metal plates in cases of hysterical or organic hemiansesthesia with 
contractures and motor palsy, there will be relief not only of the 
paralysis of sensibility but also of the disturbances of motility. 
Thus, M. Laboulbene reports a case {Gazette des Hopitaux) of a 
man, sixty-seven years of age, suffering from organic left hemi- 
plegia and complete hemianaesthesia, in whom the application of 
a strong magnet was followed by the reappearance, first in the 
arm and afterwards in the leg, of the normal sensibility, and by a 
marked increase of the motor power in the hand as tested by 
the dynamometer. It is, however, to be noted that, so far as my 
examinations of the records go, there has not as yet been re- 
ported a case of organic hemianaesthesia in which any transfer of 
anaesthesia has been noted. 

The explanation of the facts of metallo-therapy is a matter of 
difficulty, and no theory has as yet been offered which is satisfac- 
tory. That the phenomena are not the result of the action of a 
feeble electric current upon the peripheral nerves seems to be 
shown by their having been produced by metals, such as platinum, 
which are practically non-oxidizable, and by absolutely inert sub- 
stances, such as disks of wood, and even, as in the case reported 
by Bennett iloc. dt.), by the application of a handkerchief. The 
theory adopted by most English writers, that they are the result • 
of expectant attention, — i.e., that they are the result of the patient's 
believing that the phenomena are about to happen, — is asserted to 
be disproved by the fact that in many cases the patient did not 
know what was to happen. The so-called molecular theory, which 
teaches that there is some mysterious molecular influence produced 
by the applied plate on the peripheral nerve-filaments, amounts to 
nothing more than words. 

Diagnosis of Hysterical Ancesthesia. — Only in rare cases is there 
any difficulty in distinguishing between an hysterical and an 



SENSORY PARALYSIS. 263 

organic anaesthesia. Hemiansesthesia occurring in a woman is 
usually hysterical; in man it is commonly organic. There is 
a peculiar atmosphere surrounding the hysterical person which 
to the experienced physician reveals the nature of the case^ even 
when there are no distinct symptoms of hysteria other than the 
disturbances of sensibility. Almost invariably, however, a his- 
tory can be elicited of past convulsive seizures or of shifting 
paralysis, of globus hystericus, of caprices of temper or disposi- 
tion, or of other hysterical manifestations. Further, in organic 
cases the form of the palsy, the disturbances of intellection, and 
the history of the case generally strongly indicate the existence 
of organic disease. In the great majority of cases of hysterical 
hemiansesthesia the patient does not know of the existence of the 
condition. If a motor and a sensory paralysis coexist, they are 
as likely as not upon opposite sides of the body in hysterical 
anaesthesia, whilst in cerebral hemianaesthesia they are of neces- 
sity upon the same side, unless, indeed, there be two distinct 
lesions in opposite hemispheres. According to Briquet, the hemi- 
anaesthesia of hysteria is in seventy per cent, of the cases upon 
the left side. 

The recognition of hysterical hemianaesthesia is further facili- 
tated by attention to the following considerations : 

First The organic anaesthesia is fixed, and does not vary from 

day to day in its limits, whereas in the hysterical disorder very 

often the locality of the sensory palsy varies markedly from day 

today; and even when this does not occur, the exact limits of 

' sensation can be noted to shrink and increase perpetually. 

Secondly. In hysterical hemianaesthesia there are usually spots 

located within the general anaesthetic region in which there is 

hyperaesthesia or normal sensation. The school of Charcot has 

, especially directed attention to the almost universal presence of 

1 hyperaesthesia of the ovary upon the affected side. In America 

this ovarian hyperaesthesia can very rarely be demonstrated, but, 

J as has been elaborately detailed by Mitchell, there is frequently a 

I region in the groin in which hyperaesthesia exists, although the 

ovary may not be affected. This territory reaches from the line 

of the groin upward, sometimes as far as the navel. The sensi- 

' tiveness may be limited to the skin, or may be felt only upon 

deep pressure, or may be both superficial and deep-seated. Its 



264 DIAGNOSTIC NEUROLOGY. 

presence has been noted by Mitchell in cases in which the ovary 
had been removed by the surgeon. 

It is probable that spots or tracts of sensitiveness frequently 
occur in the midst of the anaesthetic region and are overlooked. 
M. Fere (Archives de Neurologie, 1882) found such a sensitive spot, 
the size of the hand, between the dorsal and lumbar regions, and 
Dr. Mitchell has called especial attention to the frequency with 
which the anaesthesia is wanting in a limited vertical space, from 
one to two inches wide, stretching from the lower cervical region 
to some position in the dorsal region. 

Psychic Anaesthesia. — In 1883 (NeuroL Centralb., xxiii.), Dr. 
R. Thomsen announced that cutaneous and sensory ansesthesias 
often exist in epileptics, and in connection with H. Oppenheim 
{Arch, fur Psychiatries xv. 558) he published, in 1884, an elaborate 
paper upon the subject. An examination of ninety-four cases of 
epilepsy showed that no sensory disturbance follows the ordinary 
motor epileptic attack, and that there is no permanent alteration \ 
of sensibility, except in the case of old epileptics, who present 
other more or less distinct symptoms of permanent functional or 
organic degradation of the cerebral cortex. Temporary anaes- 
thesia was found to occur after attacks under three circumstances : 

First, when the convulsion was followed by post-epileptic 
delirium with hallucinations. 

Secondly, when the attack was followed by violent emotional or 
psychical disturbance without delirium. 

Thirdly, when the motor epileptic convulsion was replaced by 
an abortive attack more or less violently affecting the mental or 
emotional sphere. 

It would appear from these researches that when the epileptic 
discharge does not chiefly or solely affect the motor sphere, but 
spreads itself through the upper brain-centres and causes intel- 
lectual or emotional disturbance, it is very apt at the same time to 
exert its influence upon those portions of the cortex which are 
connected with sensation. 

The absence of sensibility in many cases of insanity is notorious, | 
but, for obvious reasons, in the insane it is exceedingly difficult toi 
determine the exact limits or extent of the loss of sensitiveness.! 
Especially is this true of acute dementia, melancholy, and acutr 
mania. ' 



SENSORY PARALYSIS. 265 

OEGANIC ANESTHESIAS. 

Description of the Sensory Pathways. — Before discussing anaes- 
thesias of organic origin it seems proper to point out very briefly 
the pathway which sensory impulses follow in going from tlie 
periphery to the respective centres of the brain-cortex. From 
the surfaces of the body pass the sensory nerve-fibres^ which enter 
the spinal cord through the so-called posterior root-zones and go 
to the gray matter. 

The decussation of the spinal fibres has been much discussed. 
It appears to be the general belief of physiologists that the im- 
mediate sensory decussation is not complete, although the major 
portion of the fibres do cross over directly after entering the 
spinal cord : in accordance with this view, a sensory impulse pass- 
ing upward from the foot crosses in large part to the lumbar 
region of the cord, but to some extent continues upward without 
decussation to the dorsal or possibly even as far as the cervical 
spinal cord. The exact upward pathway of sensory impulses 
after decussation cannot be considered as finally determined ; but 
the physiological evidence which we have indicates that, whilst 
motor impulses descend along the antero-lateral columns of the 
cord, sensory impulses pass upward through the posterior columns 
and the gray matter. Many physiologists teach that the sensa- 
tions of general sensibility and the afferent impulses which give 
rise to reflex acts are transmitted by the gray matter in all di- 
rections, whilst tactile sensations travel exclusively by the pos- 
terior columns. This, however, does not seem to be fully proved : 
the facts of disease simply warrant the conclusion that afferent 
impulses of all characters find their way either through the pos- 
terior columns or through the central gray matter, and that an 
interrupting lesion of these regions is followed by loss of sensation 
of all characters in the parts below the lesion. The sensory path- 
ways through the medulla correspond in position with those of 
other portions of the spinal cord : in the pons they occupy the 
outer nerve-bundles; in the peduncles they lie in the so-called 
tegmentum, — i.e., upon the posterior or superior portions, sepa- 
rated more or less distinctly from the crusta, or motor pathway, 
by the ganglionic mass known as the locus niger. As was first 
pointed out by Meynert, after leaving the peduncles the sensory 



266 



DIAGNOSTIC NEUROLOGY. 



fibres pass upward and backward and form the posterior third 
of the so-called internal capsule, in immediate relation with the 



Fig. 9. 




posterior and external aspect of the optic thalamus on the one 
hand and with the posterior part of the lenticular nucleus on the 
other (see Figs. 9 and 10) : at this position the ascending sensory 
spinal fibres are joined by other fibres coming upward through the 
corpora geniculata and the optic thalami from the optic tract. 
Owing to the conjunction of all the sensory fibres, a lesion at this 
position produces a complete anaesthesia of special and general 
sensation upon the opposite side of the body. From the in- 
ternal capsule the sensory fibres radiate in the so-called corona 
radiata. Their exact termination in the cortex remains at present 
a matter of doubt. 



ORGANIC GENERAL ANAESTHESIA. 

A general anaesthesia of organic origin is usually due to a wide- 
spread degeneration of the brain-cortex, or to a double lesion of 
the cortex, or to a lesion occupying the posterior third of the in- 
ternal capsules of the two hemispheres, or to a wide-spread periph- 
eral neuritis. The diagnosis of the site of the lesion must be 
made from the concomitant symptoms. If there be dementia 
pointing to profound degeneration of the cerebral cortex, the diag- 
nosis of such lesion is made out ; if there be pain and marked 
tenderness over the nerve-trunks, peripheral neuritis is indicated. 



SEXSORY PARALYSIS. 267 

A spinal general anaesthesia is theoretically possible^ but in 
order for it to involve the face the lesion would have to be situ- 
ated in the medulla oblongata. If in any case of general anaes- 
thesia there were a history of slow progressive development, with 
symptoms of spinal implication and no neural tenderness, the 
probable diagnosis would be an ascending chronic lesion either of 
the posterior columns of the spinal cord or of the central gray 
matter. 

Grouty Anaesthesia. — Dr. J. A. Ormerod has called attention 
to a variety of general anaesthesia in which the patient on awaken- 
ing has a feeling of numbness, deadness, pins and needles in the 
hands and arms, and sometimes also in the legs. There is also 
loss of power, and occasionally the hands are so far paralyzed that 
the patient is unable to hold anything. Sometimes the symptoms 
pass off in the course of a few hours, in other cases they leave 
more or less permanent disablement, and even the temporary at- 
tacks are prone to recur. In some of these cases the victim is 
gouty, and with the anaesthesia are associated severe pain and stiff- 
ness. Such cases must be looked upon as probable instances of 
gouty multiple neuritis. In others of the cases reported by Dr. 
Ormerod the affection was plainly hysterical. 

ORGANIC HEMIANESTHESIA. 

Organic hemianaesthesias for clinical purposes are best divided 
into — first, those in which the special senses are not involved at 
all ; secondly, those in which the senses of taste and smell alone 
are implicated; thirdly, those in which all the special senses 
are affected. 

Organic Hemiancesihesia without Involvement of Special Senses, 

Organic hemianaesthesia without involvement of the special 
senses may, theoretically, be due to a spinal lesion situated very 
high up; to disease of the medulla oblongata; to lesion of the 
pons ; to structural changes in the peduncle, the internal capsules, 
or the cortex of the occipital lobes. 

Spinal Hemianaesthesia. — In spinal unilateral loss of sensa- 
tion the loss of sensation is upon the side opposite to the lesion, 
whilst any motor paralysis which is present is upon the side of 
the lesion. If the lesion be of such character (a gummatous 



268 DIAGNOSTIC NEUROLOGY. 

tumor springing from the membranes, for example) as to involve 
nerve-roots, an upper zone of anaesthesia may exist upon the side 
of the lesion along the upper margin of the motor paralysis. 
The motor and sensory disturbances never extend above the spinal 
lesion, and as the latter, if above the origin of the respiratory 
nerves, would of necessity produce fatal respiratory paralysis, 
spinal hemiansesthesia never involves the face or the neck, and 
very rarely the arms. 

A gummatous tumor or a transvei'se myelitis, whilst affecting 
chiefly one side of the cord, may at the same time influence to 
some extent the other side. The result would be complete motor 
palsy on the side of the lesion and anaesthesia on the side oppo- 
site to the lesion, with partial loss of power on the side opposite 
to the lesion and partial loss of sensibility on the side of the 
lesion, — all these symptoms being present only in those portions 
of the body which are below the spinal lesion. To make this 
more clear, suppose that the tumor existed upon the left side 
of the upper dorsal cord: then there would be complete loss of 
sensibility in the right leg, and partial loss in the left leg, whilst 
motion would be entirely lost in the left leg, and partially in the 
right leg. 

Bulbar Hemiansesthesia. — Acute lesions of the medulla pro- 
duce such stormy symptoms and so rapidly fatal a paralysis that 
sensory disturbances are very rarely noted : when they exist, 
they almost invariably take the form of a partial general anaes- 
thesia. 

Hemiansesthesia from Disease of Pons. — A hemianaesthesia < 
without involvement of the special senses may be due to disease' 
of the pons, when it is almost always associated with hemiplegia. . 
According to the collection of cases made by Couty {Gazette' 
Hebdom,, 1877, vol. xiv.) and by Nothnagel, small lesions situ- 
ated in the middle portion of the pons produce no anaesthesia I 
of the extremities, but only motor paralysis, whilst anaesthesia) 
results when the lesion is situated more to one side or near the 
floor of the fourth ventricle. Our pathological material does not! 
seem sufficient to warrant a positive formulation of the apparent! 
law, but indicates that destruction of the outer bundles of th€t 
pons is necessary for the production of anaesthesia. 

Owing to the high origin of the trigeminus nerve, a crossed I 



SENSORY PARALYSIS. 269 

sensory paralysis may be produced by a lesion of the pons; that 
is, the left face and the right side of the body may be anaesthetic, 
or vice vo^sa. Strictly unilateral anaesthesia may, however, result 
from a disease of the pons. The following scheme, taken from 
the paper of Dr. Sigerson {Dublin Med, Journ., vol. Ixv., 1878), 
reports the different forms of paralysis which may be produced by 
disease of the pons, and suggests names for such varieties : 

1. SIMPLE ALTERNATE PARALYSIS (mOTOR OR SENSORY). 

Bend-dexter, — Right face and left extremities. 
Bend-sinister, — Left face and right extremities. 

2. COINCIDENT ALTERNATE PARALYSIS. 

Sensory and motor paralysis of same regions. 

3. DOUBLE ALTERNATE PARALYSIS. 

Complete. 
X-shaped Paralysis, — Both sides of face and extremities of 
both sides of body affected. 

Incomplete, 

V-shaped Paralysis. — Both sides of face affected. 

Y-shaped Paralysis, — Both sides of face and extremities of 
one side of body affected. 

Lambda-shaped Paralysis, — One side of face and extremities 
of both sides of body more or less affected. 

Hemiansesthesia from Lesion of Peduncle. — A general 
hemiansesthesia without involvement of the special senses may 
result from a lesion of the peduncle. I know of no case in litera- 
ture in which sensory without motor paralysis has been proved by 
an autopsy to have been due to a lesion of the peduncle, but in a 
case reported by M. Mayor (quoted by Nothnagel) a small focal 
disease was found in the inner half of the peduncle, and during 
life motor palsy had existed without sensory disturbance. This 
would indicate that the sensory fibres run through the outer or 
superior portion of the peduncle. In all reported cases of lesion 
of the peduncle the hemiansesthesia and hemiplegia have both 
been on the side opposite to the lesion, whilst the oculo-motor 



270 



DIAGNOSTIC NEUROLOGY. 



paralysis, when it has existed, has been upon the same side as 
the lesion, and therefore is crossed with the hemianaesthesia and 
the hemiplegia.* 



Fig. 10. 




Cerebral Hemiansesthesia. — A unilateral sensory paralysis 
not implicating the special senses may be due to a lesion in the 
brain, provided such lesion be so situated as to avoid the fibres of 
special senses. According to Meynert, a very limited lesion in 
the optic thalamus near the geniculate bodies is capable of par- 
alyzing solely the fibres connected with the special senses. A 
little in front of this the fibres of general sensibility are fused 
with those of the special senses. More in front the fibres con- 
nected with general sensibility exist by themselves, and conse- 
quently a minute lesion at such point would produce a hemian- 
sesthesia without aflfection of the special senses. A hemorrhage 
or minute tumor in the anterior portion of the optic thalamus, 
or in the lenticular nucleus, might therefore by pressure paralyze 
the fibres of general sensibility without affecting those of special 

* The case reported by Dr. G. E. Paget (Med. Times, 1855, vol. xxxi.) has 
been widely quoted as exceptional. In it a tumor was found springing from 
the right crus, although during life there had been oculo-motor paralysis of 
the left side, with right hemiansesthesia and right hemiplegia. It is plain, 
however, that the lesion involved the left crus more than it did the right, for 
we are told that the "mass commenced a little posterior to the junction of 
the crura, and extended obliquely forward from the right i7ito the left c?'ws." 
The case cannot, therefore, be considered as exceptional. 



SENSORY PARALYSIS. 271 

sensation^ and thereby give rise to a hemiansesthesia without dis- 
order of the senses. 

The disturbance of sight which occurs in cerebral hemianaes- 
thesia is always an homonymous hemianopsia, — that is, a hemian- 
opsia which affects the same side of each eye. The details and 
explanation of this will be given in the chapter on Special Senses. 
The brief formulation of the diagnostic points is, that when 
both nasal or both temporal fields are affected the lesion is in the 
optic chiasm and not within the cerebral hemispheres, but that 
when a temporal and a nasal field are conjointly paralyzed the 
region is within the cerebrum. 

Hemiancesthesia involving Special Senses. 

Hemiansesthesia involving some, though not all, of the special 
senses, although very rare, does occur. As is shown in the col- 
lection of cases made by Gouty, in hemiansesthesia due to disease of 
the pons the senses of smell and taste may be involved without any 
disturbance of vision or audition. Loss of taste is to be expected 
in the lesion of the pons, because the gustatory fibres of the 
glosso-pharyngeal nerves pass through the pons; but it is difficult 
to explain the loss of smell, except by supposing that the pons 
lesion is situated so far anteriorly as to press upon the olfactory 
bulbs, or else that it is placed so far posteriorly as to encroach 
upon the immediately contiguous uncinate convolutions, in which 
some physiologists locate the sense of smell. Hemiansesthesia 
with loss of hearing and sight without implication of the senses of 
smell and taste probably never occurs as the result of an intra- 
cerebral lesion. I have, however, seen one case in which there 
was partial hemiansesthesia with epileptic attacks, Jacksonian in 
type, complete hemianopsia, and partial loss of hearing upon one 
side, with demonstrable alteration of taste and smell, all due to a 
band-like gumma which stretched obliquely across the anterior 
end of the pons, reaching as far forward as the cribriform space. 
The corpora quadrigemina and the optic tract were involved in 
the exudation, as was also the auditory nerve of one side : hence 
the affection of sight and hearing. One end of the tumor was 
much thicker and heavier than the other, and consequently there 
was a slight hemiansesthesia and hemiplegia. In a case of this 
character the basal situation of the lesion is plainly revealed during 



272 DIAGNOSTIC NEUROLOGY. 

life by the hemianopsia not being homonymous : thus^ in the case 
just detailed, both the temporal fields were paralyzed. 

Complete hemiansesthesia involving both common sensibility 
and the special senses not rarely coexists with hemiplegia. Under 
these circumstances, if the symptoms are the result of a single 
lesion the hemianopsia is always homonymous. The lesion must 
be higher up than the geniculate bodies, and must be sufficiently 
large to destroy or to paralyze by pressure the whole of the inter- 
nal capsule, except the anterior segment, which contains cerebellar 
fibres: in other words, the lesion must directly or indirectly par- 
alyze the posterior segment and the knee of the internal capsule. 

I have seen several cases in which hemianopsia coexisted with 
hemiplegia and with absolute aphasia, but have never had an op- 
portunity to make the autopsy of such cases. As the fibres of 
the facial and hypoglossal nerves are believed to run through 
the knee of the capsule (see Fig. 10), a lesion at such place might 
affect articulation ; but in the cases of which I am now speaking a 
true amnesic aphasia existed. So far as present knowledge goes, no 
destruction of the internal capsule is able to produce such aphasia. 
The knee of the capsule is, however, about on the same level in 
the brain as the island of Reil, so that a large clot in the lentic- 
ular nucleus, which lies between the island of Reil and the knee 
of the capsule, might, by pressure, paralyze on one side Broca's 
convolution, and on the other side the internal capsule, thereby 
producing complete hemiansesthesia, hemiplegia, and aphasia. An 
embolus of the middle cerebral artery might also produce these 
symptoms by destroying a large area of the brain-cortex. When, 
however, symptoms in a case are complicated and, as occasionally 
occurs, in a measure contradictory, there is always a possibility of 
a double lesion. 

ORGANIC PARANESTHESIA. 

Paransesthesia is in the vast majority of cases of spinal origin. 
Theoretically, it might be produced by two coexisting brain- 
lesions, and a multiple neuritis confined to the lower extremities 
would cause it. In the latter case the pain and tenderness over 
the nerve-trunks would reveal the nature of the affection. 

For diagnostic purposes cases of paranesthesia are to be divided 
into four groups : 



SENSORY PARALYSIS. 273 

1. Cases in which the development is abrupt. 

2. Cases in which a few hours are required for the production 
of the symptoms. 

3. Cases in which some days are necessary for the production 
of the symptoms. 

4. Cases in which many months are required even for the 
partial development of the symptoms. 

First. A paransesthesia abruptly developed without much pain 
is characteristic of hemorrhage into the spinal cord. Under these 
circumstances it is complete, and afiFects the rectum and genito- 
urinary organs. A very sudden paransesthesia is sometimes pro- 
duced by embolism and consequent arrest of function and soften- 
ing of a portion of the cord. It may be produced by a traumatism, 
such as a stab or other injury, which suddenly puts an end to the 
functions of the spinal cord. 

Second. A paransesthesia which has come on in the course of 
a few hours and has been associated with great pain is almost 
certainly due to rupture of a blood-vessel within the spinal mem- 
branes. 

Third. A paransesthesia which becomes nearly complete in the 
course of a few days usually is caused by a central myelitis or by 
a very rapid transverse myelitis. A more slowly developed par- 
anaesthesia may be the result of a subacute myelitis, or of soften- 
ing of the cord, or of a rapidly-developed tumor. 

Fourth. Chronic sclerosis aflFecting the posterior columns of the 
cord, whether it occurs in foci or in tracts, produces below the 
lesion a loss of sensibility which is characterized by extreme 
slowness of development ; by its rarely, even in its later stages, 
becoming complete ; and by its connection with loss of knee-jerk or 
of co-ordination, shooting pains, or other well-known symptoms 
of locomotor ataxia. 

ORGANIC MONOANESTHESIA. 

Monoansesthesia may be produced by a cortical lesion affecting 
centres in the occipital lobe which are connected with sensation. 
It may also be caused by a wide-spread traumatic or idiopathic 
neuritis. Thus, I have seen it as the result of concussion and 
subsequent inflammation of the brachial plexus, due to a curling 
storm- wave giving a downward stroke from above the clavicle. 

18 



274 DIAGNOSTIC NEUROLOGY. 



ORGANIC LOCAL ANAESTHESIA. 



Local anaesthesias may be the result of narrowly-defined corti- 
cal brain-lesions, or may be produced by traumatisms or diseases 
of the nerves themselves. The most ordinary forms of local an- 
aesthesias are those which accompany motor paralysis due to 
pressure upon nerve-trunks. A partial local anaesthesia often 
accompanies neuritis, and may even be associated with a true 
hyperaesthesia ; that is, an inflamed nerve may lose its functions of 
special sensibility, and at the same time be excessively susceptible 
to the pain-reaction ; so that, although the slightest touch upon 
the part may produce severe pain, the patient is unable accurately 
to locate the points of the compass or to distinguish degrees of 
temperature. 

Anaesthesia produced by section of the nerve would be expected 
to follow the distribution of such nerve as given in standard treat- 
ises upon anatomy; but the results of clinical observation of the 
effects of section of nerves show that this expectation is not thor- 
oughly realized. Thus, a principal nerve of the brachial plexus 
may be divided without giving rise to complete anaesthesia in any 
way ; and when a complete anaesthesia does result, the portion of 
the surface so affected is very limited, and often the area of par- 
tial anaesthesia does not correspond with the generally recognized 
anatomical distribution of the nerve. Moreover, the division of 
the same nerve in different people produces different results in 
its relation to anaesthesia. Anaesthesia the result of nerve-section 
tends to become progressively less in degree and extent with the 
lapse of time. 

I shall not enter into an elaborate discussion of this subject, 
but shall give a series of figures representing observations made 
by several observers. For details the reader is referred to the 
paper of Dr. James Eoss {Brain, vol. vii. p. 50), to the work of 
E. L6ti6vant {TraiU des Sections nerveuses, Paris, 1873), and to the 
articles referred to by the writers just named. 

Fig. 11 represents the distribution of the cutaneous nerves as 
given by Flower ; I H, W, I C B, respectively, representing the 
intercosto-humeral nerve, the nerve of Wrisberg, or small internal 
cutaneous nerve, and the internal cutaneous nerve, all derived 
from the roots of the eighth cervical and the first and second 



SENSORY PARALYSIS. 



275 



dorsal nerves; S A, the supra-clavicular and supra-acromial 
branches of the cervical plexus ; C, the circumflex nerve ; I C B 



Fig. 11. 




Fig. 12. 



and E C B, the internal and external butaneous branches of 
the musculo-spiral nerve; M C and M C B^ the cutaneous 
branches of the musculo-cutaneous 
nerve, probably derived from the fifth, 
sixth, and seventh cervical roots; R, 
the radial nerve, and U, the ulnar 
nerve. The distribution of the nerves 
in the hand given by Krause appears 
to be more in accord with clinical 
results than that which is usually ad- 
hered to by the English anatomists. 

Fig. 12 represents this distribution, 
the letters standing for the nerves 
whose names they begin. 

Fig. 13, after L6ti6vant, represents 
the effects of an anaesthesia which 
followed section of the sciatic nerve. 
The dark shading signifies total anaesthesia, the lighter, partial 




276 



DIAGNOSTIC NEUROLOGY. 



anaesthesia : the depth of the shading represents the intensity of 
the loss of sensation. 

Fig. 13. 






\ 



Fig. 14, after James Ross, shows the interior and posterior 
aspects of an arm after a rupture of the brachial plexus, in which 
the motor fibres from the fourth cervical nerve probably escaped. 
The loss of sensation in the part was complete. 

A section of the brachial plexus, reported by Maury and Duh- 
ring (Amer. Jour, Med. Sci., ii., 1874), was followed by a loss of 
sensation in the forearm and a disturbance in the upper arm, 
indicated in Fig. 15 : the interrupted line marks the boundary of 
the anaesthesia on the inner surface of the arm, whilst the unin- 
terrupted line a a marks the boundary of the anaesthesia on the 
outer surface of the arm. This case would seem to show that 
the intercosto-humeral nerve and the descending branches of the 
cervical plexus supply most of the inner surface of the upper arm 
and a little of the outer surface. 



SENSORY PARALYSIS. 



277 



Fig. 16^ after L6ti6vant, represents the loss of sensation two 
years and a half after division of a musculo-spiral nerve by a 
poniard. The depth of the shading indicates the degree of 
sensory palsy. The area of the anaesthesia in this case is remark- 



EiG. 14. 





ably in contrast with that of the anaesthesia which followed in a 
case of Dr. S. Weir Mitch elPs division of the musculo-spiral and 
median nerve, as represented in Fig. 17 : in this figure the 
light shading indicates the area in which tactile sensibility was 
diminished, and the deep shading, that in which it was lost. 



278 



DIAGNOSTIC NEUROLOGY. 



The marks > < indicate the appreciation of separate points. 
A single mark (V) indicates that the points are not felt as sepa- 



FiG. 15. 




Fig. 16. 




PALMAR 7(. 
^<^^ I HYPEf 




rate. The absence of the mark indicates complete loss of tactile 
sensibility. H indicates a small area in which there was hyper- 
algesia of the skin. 



SENSORY PARALYSIS. 



279 



Fig, 18, after Letievant, represents the distribution of anaes- 
thesia after a complete division of the ulnar nerve at the wrist ; 
the darkest shading indicating complete loss of sensation, the 
lighter shading, partial loss, in proportion to the depth of the 
shading. 

Fig. 18. 

n 




Fig. 19, after Leti^vant, shows the radial border and the dor- 
sal aspect of the hand after division of the median nerv^e. From 



Fig. 19. 




five divisions of the median nerve carefully observed, L^tievant 
concludes that the anaesthesia is distributed over the palmar sur- 
faces of the thumb, index, and radial border of the middle finger, 



280 



DIAGNOSTIC NEUROLOGY. 



the thenar eminence, and the radial half of the palm, and over the 
dorsal surfaces of the ungual and middle phalanges of the index 
and middle fingers, and occasionally the ungual phalanx of the 
thumb. The anaesthesia is only partial, except over the palmar 
surface of the whole of the ungual phalanx of the index finger 
and part of the dorsal surface of the same phalanx. 

Fig. 20. 




Fig. 20, after James Ross, shows the anaesthesia which fol- 
lowed the division of the ulnar and median nerves. 



CHAPTEE VIL 

EXALTATIONS OF SENSIBILITY. 

HYPEE^STHESIA. 

By the term hypersesthesia, as used in this book, is meant a 
condition of the sensory nervous system which causes it to re- 
spond more actively than normally to irritations. This condition 
is closely associated with pain, but is distinct from it, since a part 
may be hypersesthetic and yet not painful so long as no external 
irritation is present. Often a part is both painful and hyperaes- 
thetic. Thus, an inflamed nerve suffers from pain originating 
within itself, and is also excessively sensitive to external irrita- 
tions. Precisely as anaesthesia of special sensibilities may coexist 
with or may exist separately from anaesthesia of general sensi- 
bility, so may special and general hyperaesthesias exist alone or to- 
gether. Hyperaesthesia or excessive functional activity of special 
sensibilities is, however, rare, although there are hysterical cases in 
which there is a positive increase of sensibility as regards the dis- 
crimination of locality and of temperature. Probably one expla- 
nation of the extreme infrequency of increase of special sensibili- 
ties is to be found in the fact that whenever a specialized nerve 
becomes hyperaesthetic it is very prone to respond, even to its 
normal stimuli, by pain rather than by extraordinary acuteness of 
functional activity. Thus, a hyperaesthetic eye commonly does 
not see more acutely than normal, but suffers intensely under the 
stimulus of light. There is, however, in hysteria occasionally 
hyperaesthesia of the special senses, in which, with or without 
the coexistence of the pain-reaction, there is an excessive func- 
tional power, so that the eye will see clearly in a darkened room, 
or the ear will hear sounds which are inaudible to the normal 
ear. 

For the purposes of study and discussion, hyperaesthesias may 
be divided into Hysterical Hyperaesthesia, Psychical Hyperaes- 
thesia, and Organic Hyperaesthesia. 

281 



282 DIAGNOSTIC NEUROLOGY. 



HYSTERICAL HYPERiESTHESIA. 



Hysterical hyperaesthesia may follow the regional distribution 
which is common in anaesthesia of the same nature : usually, how- 
ever, it is more irregular in its distribution, occurring in patches 
which may interrupt anaesthetic tracts. Concerning these inter- 
rupting tracts sufficient has already been said under the head of 
Anaesthesia. It seems here necessary only to point out in detail 
certain forms of local hysterical hyperaesthesia which are liable to 
be confounded with disease of other character. 

Genital Hyper sesthesia. — Among the local hysterical hyper- 
sesthesias to be here mentioned is hyperaesthesia of the genital 
organs. This, seen almost exclusively in the female, is rarely 
associated with an excess of sexual desire, but usually gives rise 
to severe pain during the sexual act, and often lies at the foun- 
dation of the vaginal spasm known as vaginismus. 

Hysterical Breast. — An important and common form of local 
hyperaesthesia is the hysterical or neuralgic breast, which has fre- 
quently been mistaken for cancerous or other organic disease. The 
breast is often much swollen, and the pain excessive, sometimes 
shooting down the arm and being made worse by using the arm. 
The diagnosis between this condition and organic tumor of the 
breast can usually be made without difficulty by paying attention 
to the following points. In the first place, the tenderness is exces- 
sive, and is superficial, so that as much pain is produced by merely 
brushing or handling the breast as by hard pressure. In organic 
tumor the pain is proportionately increased by pressure. Again, 
the swelling is more diffuse in the hysterical breast, and lacks the 
definite limitation usually seen in organic disease. If a distinct 
tumor be simulated, it is commonly less persistent in form and 
more tender than is the organic alteration. The neurotic breast 
varies in size and in consistency continually, and is often enlarged 
and more painful at the menstrual period ; the pain is often ex- 
cessive, and is increased by the approach of stormy weather and 
by general fatigue. In almost all cases marked evidences of the 
neurotic or hysterical temperament exist. 

A form of the neurotic breast which not rarely gives rise to 
alarm on the part of parents occurs at the age of puberty. When 
the system is expanding from childhood to womanhood the breasts 



EXALTATIONS OF SENSIBILITY. 283 

usually become swollen and tender, but if all the genital organs 
unfold themselves simultaneously no thought is taken about the 
matter. In neurotic young girls there is often, however, irregu- 
larity of sexual unfolding, so that while one breast remains as 
heretofore the other suddenly grows hot, and so painful and tender 
as materially to impede the use of the arm. I have seen a num- 
ber of similar neurotic breasts occurring in boys at the age of 
puberty, and even attended with the secretion of a few drops of 
sero-lacteal fluid. 

Hysterical Joints. — Hysterical patients are very liable to 
affections of the larger joints simulating a chronic inflammation, 
but due to a neurotic hypersesthesia. Of all the larger joints the 
knee is the one most usually attacked. The hysterical disease of 
this joint is to be recognized by attention to the following consid- 
erations : jirstj the muscular rigidity or contraction can be over- 
come by mildly persistent efforts while the patient's mind is 
diverted, yields readily during natural sleep, and disappears during 
slight anaesthesia, or even under a full dose of chloral or opium : 
secondly^ there is no rise of temperature in the joint, although 
the part looks red and inflamed : thirdly^ the reaction of the con- 
tracted and apparently atrophied muscles to the faradic current is 
normal. 

In organic disease of the knee, relaxation never takes place 
except in profound anaesthesia, the temperature of the surface is 
above normal, and the faradic reaction of the affected muscles is 
lost. 

A mimetic disease of the hip-joint is often distinguished with 
some difBculty from the organic affection. It is to be recognized 
by noticing that the apparent tenderness of the limb as revealed 
by the limp varies greatly from time to time, and especially is less 
when the attention of the patient is diverted : it is also made worse 
by fatigue or nervous excitement, and hence is usually much more 
distinct in the evening than in the morning. Pain, which in the 
organic disease commonly follows the limp in the order of its de- 
velopment, in the hysterical disease generally precedes the limp. 
The muscular rigidity in the hysterical affection varies greatly, 
and can be readily overcome by chloral and anaesthetics, and dis- 
appears during sleep. Even if muscular atrophy exists, the normal 
electrical contractility is preserved. The evidences of the hys- 



284 DIAGNOSTIC NEUROLOGY. 

terical temperament abound in this as in all other mimetic joint- 
affections, and the symptoms are much less severe when a great 
desire arises on the part of the patient to perform acts requiring 
exertion. 

Spinal Hypersesthesia. — An important local form of hyster- 
ical hypersesthesia is that which is present in the so-called spinal 
irritation, or spinal ancemia. This condition, which by many 
writers of text-books on nervous diseases is raised to the rank of 
a distinct disease, is exceedingly frequent and variable in degree. 
In a very large proportion of neurotic young women there exists 
a tract somewhere in the spinal column which is especially tender 
to touch. The ordinary position is between the shoulders ; the 
hypersesthetic region may, however, be as low as the lower lumbar 
or as high as the upper cervical vertebrae. Even in moderate 
cases a slight touch produces a sense of faintness, and sickness of 
the stomach, and I have seen cases so severe that painting with 
a cameFs-hair brush would cause excessive agony, and, if per- 
sisted in, even general convulsions, — cases in which the laying of 
a hand or even the touch of a pillow on the back would make 
the patient fall in the bed and lie for days apparently at the 
point of death, unable to turn or to speak, save in the faintest 
of whispers. In such women violent hysterical convulsions occur 
occasionally. The symptoms are commonly intensified by fatigue, 
and not rarely much pain between the shoulders is complained 
of. This pain is increased by jarring, and by any prolonged use 
of the arms. There is not, to my mind, the slightest evidence of 
the existence of anaemia or congestion or of any other recognizable 
alteration of the spinal cord in this so-called spinal irritation. 
The diagnosis is very easy: in serious disease of the vertebrae, 
and even in inflammation of the posterior nerve-roots, the sen- 
sitiveness is not so extreme, and usually cannot be developed 
except by firm pressure. Further, hyperaesthesia of the spinal 
region, unless excessively severe, is not accompanied by spasm of 
the spinal muscles or restriction of the movements, such as are 
seen even in incipient disease of the vertebrae. When to these 
facts are superadded the existence of the hysterical constitution, 
the absence of evidences of severe constitutional disorder, and the 
shifting, varying, evidently neurotic type of the tenderness itself, 
the character of the case becomes evident. 



EXALTATIONS OF SENSIBILITY. 285 

ORGANIC HYPERESTHESIA. 

Organic hypersesthesias replace organic anaesthesias when the 
lesion irritates rather than paralyzes : hence, theoretically at least, 
it is possible to have hemihypersesthesias, parahypersesthesias, 
monohypersssthesias, etc., each corresponding to an organic anaes- 
thesia. Clinically, however, hypersesthesias due to disease of the 
nerve-centres themselves are so exceedingly rare that detailed 
consideration of them does not seem necessary. It is otherwise 
with disease of the membranes which cover the nerve-centres. 
The roots of the sensitive nerves pass through the spinal mem- 
branes, and have for their sheaths the prolongations of such mem- 
branes : consequently inflammation of these membranes gives rise, 
almost of necessity, to an inflammation of the posterior or sensory 
nerve-roots, with the necessary production of pain and hyper- 
sesthesia. These sensory symptoms are always accompanied by 
spasm of the muscles, on account of the coexistent inflammation 
of the motor roots. The groups of symptoms which are thus pro- 
duced have been sufficiently detailed under the head of Spasmodic 
Affections (see page 168). It seems only necessary here to point 
out that hypersesthesia of the neck and face may be symptomatic 
of inflammation of the basal brain-membranes, and lateral hyper- 
sesthesias and hyperaesthesias in the limbs, of inflammation of the 
spinal membranes. 

PAE^STHESIAS. 

Under the name of parsesthesias may be grouped the almost 
innumerable disagreeable sensations which accompany functional 
and organic nervous diseases, and which are usually referred to 
the surface of the body, or more rarely to mucous tracts. Such 
are formications, prickling, a feeling as of the flowing of water or 
of the crawling of ants or other insects over the surface, itching, 
flushes of heat, waves of cold, etc. These symptoms may be due 
to hysteria, and are very common in women at the climacteric 
period, even when no distinctly hysterical symptoms are present. 
In rare cases of insanity they are psychical, — i.e.y of the nature of 
a delusion, the subject simply imagining their existence. They 
may be produced by various poisons. They are often the result 
of disease of the spinal cord, either simple congestion, myelitis, or 



286 DIAGNOSTIC NEUROLOGY. 

the curious condition which occasionally follows spinal concussion. 
When localized in one arm or in one side of the body, they may 
be produced by local brain-alterations, and occasionally they exist 
as prodromes of hemiplegia. 

When parsesthesias are not hysterical or due to disease of the 
spinal cord, they are usually the outcome of some poison in the 
blood, — notably either the gout-poison or lead. In a case which 
had been under the care of most of the leading neurologists in 
the United States without plumbism having been suspected, the 
chief symptoms were an apparent insomnia, with horrible itching 
over the whole surface, and itching, with burning pains, in the 
urethra. A chemical examination of the urine and of the water 
habitually drunk by the patient demonstrated the existence of 
lead in each. The insomnia was undoubtedly due to the paraes- 
thesia. 

PAIN. 

Pain is a symptom so variable and so universal that it is diffi- 
cult to discuss it properly in connection with one class of diseases. 
Its importance, however, necessitates its consideration. In esti- 
mating the intensity and the diagnostic value of pain, it must be 
remembered that what may be called the pain-reaction varies 
almost indefinitely in individuals. A disease which in one person 
produces a veritable agony will in another cause but little suffering. 
It is stated that an old hardened cart-horse will quietly eat his 
oats whilst the operator is cutting down upon the thoracic duct, 
although a thoroughbred squeals, plunges, and becomes entirely 
unmanageable at the first touch of the scalpel. In man the dif- 
ferences in sensitiveness are as great as in the horse. Moreover, 
the statements of patients vary enormously in regard to pains of 
equal intensity. The hysterical person habitually overstates his 
sufferings: indeed, the peculiar exaggeration leads the experi- 
enced practitioner almost at once to a correct diagnosis. A very 
important assistance in the recognition of an hysterical or other 
exaggerated pain is to be obtained by noticing the disagreement 
between the words of the patient and the expression of the face. 
A well-timed compliment to a woman groaning in agony will 
often bring the reward of a momentary pleasant smile or expres- 
sion of gratification and the consequent discovery of the meaning 



EXALTATIONS OF SENSIBILITY. 287 

of the alleged pain. Sometimes the words and the expression of 
the face perpetually give the lie to each other. Again, by skil- 
fully distracting the attention of the patient, the pain or alleged 
tenderness can often be caused to disappear : thus, engaging the 
patient in active conversation may cause her not to notice firm 
pressure upon the spot which is alleged to be intensely sore. 

As most local inflammations, ulcerations, or other organic 
changes produce more or less pain, it is essential that a careful 
examination be made to discover the existence of any local disease 
before the consideration of the nervous origin of the pain is 
entered upon. In the discussion which follows in this chapter it 
will be taken for granted that such examination has been made : 
all the diagnostic procedures and rules given are founded upon 
the supposition that the existence of local disease has been ex- 
cluded. 

The diagnostic import of pain in nervous diseases is best 
studied by dividing the body into three regions, and discussing 
each of these separately. These regions are the extremities, the 
trunk, and the head. 

Neuralgic Temperament. — Before taking up the systematic 
consideration of the various localized nerve-pains, it seems neces- 
sary to say a few words in regard to the obscure but intolerable 
pains which may be included under the term Neuralgia. For- 
merly almost all forms of nerve-pains were spoken of as neuralgic, 
so that whenever there was a lack of obvious local lesion, such 
as of abscess, etc., the patient was said to be suffering from neu- 
ralgia. Most of the varieties of localized pains which will be 
treated of in subsequent sections have been split off from neu- 
ralgia, but there yet remain pains for which we cannot account, 
and to which, therefore, the term neuralgia is still applied. In 
many cases autopsies will show that the supposed neuralgic pain 
was caused by a definite lesion : thus, a clot forming near the 
trigeminal nerve-centre, or a spicule of bone hidden from exter- 
nal view pressing upon a nerve in such a way as to irritate it 
occasionally but not to provoke a defined neuritis, would give rise 
to pain that during life might have to be termed neuralgic. 
There is, however, a final group of cases in which neither during 
life nor after death are we able to detect any cause for the pain. 
It would seem that there may be a molecular change either in the 



288 DIAGNOSTIC NEUROLOGY. 

sensory nerve-centres or in the nerves themselves so fine as to escape 
our instruments, which predisposes the individual to suffer, so 
that a change of weather or other untoward influence too slight to 
be felt by the normal man causes a pain-storm. In a large pro- 
portion of cases neuralgia is undoubtedly of gouty or lithsemic 
origin ; but it has seemed to me that we must acknowledge that 
there is also a general condition which may be known as the neu- 
ralgic temperament or diathesis. This is often inherited, but may 
be developed by prolonged bodily exhaustion or other causes. 
When once acquired, it may persist although the original cause 
has been removed. The pains which come to some persons in 
malarial ansemia probably are often neuralgic, but wlien the 
anaemia has been relieved, if the nervous system has been suffi- 

. ciently long impressed, the pain-tendency becomes stamped upon 
it, precisely as the epileptic tendency becomes constitutional in a 
case of reflex epilepsy and persists after the removal of the origi- 

. nal irritation. These neuralgic pains are to be recognized by their 
persistency, by the absence of cause, and by the excluding of all 
other sources of pain. I believe that the acquired or inherited 
neuralgic temperament frequently is closely connected with or 
complicates some of the pains hereafter to be described. Thus, I 
have seen cases of migraine in which, besides the definite attacks, 
there were not rarely seizures in various parts of the body, and 
still more frequently a complete departure of the migraine from 
its typical characteristics. Under these circumstances possibly a 
neuralgic temperament is superadded to an inherited migraine. 
The neuralgic temperament is undoubtedly closely allied to inher- 
ited gout; but the facts that the neuralgic temperament so often 
corresponds with the general neurotic temperament, that it is more 
frequent in women than in men, and that it is so often prevalent 
in dry neurotic climates and in persons free from gouty symp- 
toms, indicate that the neuralgic temperament is something more 
than a gouty diathesis. 

Reflex Pains. — Although in the following pages much will be 
said in regard to the occurrence of pains at a distance from the 
point of irritation, some general remarks upon the subject seem 
necessary. Precisely as there may be reflex disturbances of mo- 
tility, so may we have reflex sensory disturbances. Usually the 
pain is felt in some region near to, or at least in relation with, the 



EXALTATIONS OF SENSIBILITY. 289 

seat of irritation. Thus^ Anstie describes several cases of neu- 
ralgia in the urethra and testicles as the result of self-abuse. A 
facial pain caused by a diseased tooth may be due to a propagated 
neuritis ; but that such pain may be reflex is shown by its not 
rarely occurring upon the side of the head opposite to the affected 
tooth, and also by the cases reported by Dr. Ferrier (Th^e, 1884, 
p. 376), in which facial neuralgia was produced simply by the 
irritation of tartar upon the teeth. Other not uncommon in- 
stances of neuralgic pains occurring near the seat of the irritation 
are the intestinal neuralgia which often accompanies impacted 
faeces, and the pain in the bladder which sometimes results from 
fissure of the anus. Although usually thus close at hand, the 
reflex neuralgic pain may be at a long distance from the irritated 
point and have no apparent connection with it. Thus, I have 
seen a mastoid pain, so violent as to lead to the diagnosis of disease 
of the bone and to a deep incision, caused by tapeworm in the 
large intestine ; and in the thesis of Ferrier, quoted above, there 
are recorded instances of cervico-brachial neuralgia resulting from 
a diseased tooth. The recognition of the character of the pain in 
these cases depends upon the acuteness of the physician in per- 
ceiving the absence of other causes and the presence of the irri- 
tation. 

PAINS IN THE EXTREMITIES. 

A persistent pain occurring in the legs or in the arms, and not 
dependent upon obvious local disease, may be due — 

1. To gout or rheumatism. 

2. To neuritis. 

3. To chronic metallic poisoning. 

4. To disease of the spinal cord. 

5. To neuralgic or malarial cachexia or other obvious or ob- 
scure cause. 

In deciding to which of these categories any individual case 
belongs, the diagnosis must, to some extent, be reached by the 
process of exclusion, and aid must be obtained from the concomi- 
tant symptoms. The character of the pain, although of some 
importance, is not decisive, for the same quality and severity of 
pain may arise from various causes, and in different individuals 
the same cause varies almost indefinitely in its pain-effects. 

Pain is mobile, shifting, or darting, or it is fixed in one spot. 

19 



290 DIAGNOSTIC NEUROLOGY. 



Fixed Pains. 



A permanent fixed pain may be the result of a neuritis, but is 
in the great majority of cases the expression of gout or of rheu- 
matism. This is especially the case when it is associated with 
tenderness upon pressure or upon motion. A fixed pain may be 
the result of a sprain or other injury ; but a traumatism may 
cause the fixation of a general rheumatic irritation in the injured 
part, so that care is sometimes necessary to prevent being deceived 
in the diagnosis. If a rheumatic seizure be very sudden, and 
occur at the time of making an exertion, the pain may be sup- 
posed to be the result of an injury. Thus, I saw, not long since, 
a grocer who had been under professional care for nearly a year 
for strain of the back. I found, however, that at the time of the 
sudden coming-on of the pain he was lifting only a few pounds, 
whereas he had been accustomed for years to lift occasionally a 
barrel of flour without injury. There was also a distinct history 
of exposure to damp, with increase of the pain at night and on 
change of the weather. On putting the patient on anti-rheumatic 
treatment, relief was soon afforded. In another case a gentleman 
springing from a wagon was perfectly well when he left his car- 
riage, but on reaching the ground had a disabling pain at the 
insertion of the tendon of the right patella, and supposed that he 
had wrenched his knee. It turned out, however, that the attack 
was rheumatic. 

The mere permanence of the gouty or rheumatic pain some- 
times misleads the practitioner, especially when it affects the ex- 
tremities symmetrically. A rheumatic pain may continue in a 
single spot for months, and even for years, and may be located in 
exactly corresponding portions of opposite limbs. A rheumatic 
pain is to be distinguished from a pain of nerve-origin by the 
tenderness on pressure and on active movement, and also by the 
pain which is elicited when passive movements are so made as 
forcibly to stretch the affected muscle. 

Mobile Pains. 

The diagnosis of the nature of mobile pains is often one of much 
difficulty. In deciding the nature of such a pain the first consid- 
eration is as to whether it is unilateral or bilateral. The lesions 



EXALTATIONS OF SENSIBILITY. 291 

of the spinal cord itself which produce pains are almost invari- 
ably bilateral. In the beginning of a syphilitic or other localized 
disease of the spinal membranes, one side may be affected, and 
consequently a unilateral pain be produced by involvements of 
the spinal roots of that side. It is rare for a localized meningeal 
affection to be situated so low as to implicate the nerves going to 
the legs: consequently, only in the rarest cases is a unilateral pain 
in the leg due to disease of the cord or of its membranes. In 
like manner, a pain situated in one arm and not in the other 
is practically never due to disease of the cord itself, and only in 
rare instances to an affection of the membrane. A unilateral 
pain in an extremity is therefore, except in the rarest of cases, not 
due to organic disease of the nerve-centres or of their membranes. 

Pains which are the result of a general toxaemia are apt to be 
bilateral, because the nervous system on each side of the body is 
equally under the influence of the poison, but, as already stated, 
the constitutional disorder may for long periods of time expend 
itself upon one point. If the toxaemic unilateral pain be darting, 
shooting, or shifting, it is due to the constitutional affection influ- 
encing a nerve- trunk, so that it may be laid down as a general 
diagnostic rule, whose exceptions are exceedingly infrequent, that 
a unilateral pain either in the arm or in the leg is due to an inflamma- 
tion of the nerves themselves, which neuritis is generally the result of 
a constitutional disorder, — alcoholism, gout, rheumatism, syphilis, 
etc. In the examination of a case suffering from a unilateral 
pain in the leg, pressure upon the sciatic nerve at its emergence 
from the pelvis, upon the popliteal nerve, or upon some of the 
smaller nerve-trunks, will, as a rule, detect the existence of dis- 
tinct tenderness, or such tenderness of the nerve-trunks will be 
made manifest on stretching the nerve by forced movements of 
the limbs. In the arm the brachial plexus or its branches will be 
found sore. Under these circumstances the diagnosis of neuritis 
becomes plain, and in the majority of cases such neuritis is rheu- 
matic or gouty. 

Theoretically, we should expect to find cases of unilateral 
nerve-pains in the extremities without tenderness of the nerve- 
trunks and without obvious cause, — pains parallel to those so 
frequent in the head, — but, for some reason as yet unknown, 
these obscure nerve-storms are very infrequent in the extremities. 



292 DIAGNOSTIC NEUROLOGY. 

One of the most characteristic symptoms of posterior sclerosis 
of the spinal cord is the pain. As this pain may precede by 
many years other manifestations of the disease, its study is of 
great importance from a diagnostic point of view. In a majority 
of cases the legs are the first portions of the body to suffer. In 
the rare instances in which the sclerosis commences in the upper 
portions of the cord the arms are primarily implicated, and even 
the region of the face may be the first to be invaded. The pain is 
usually very severe and momentary. It is variously described by 
the patients as shooting, darting, as a feeling as though lightning 
were shooting through the part, or as though a red-hot wire or a 
sharp dagger were thrust through the limb; rarely it is burning. 
In some cases these so-called fulgurant pains occur continually ; 
in other instances they come on in paroxysms, which may in their 
severity amount to a veritable crisis. Even if they have been 
habitually present for a length of time, they may cease for a 
time. Sometimes they distinctly follow the distribution of the 
nerves. They are commonly felt severely in the neighborhood of 
joints: thus, the inside or the outside of the knee, or the inside 
of the ankle, is often the seat of violent darts. Usually they are 
not associated with redness or any soreness, and often tlie patient 
seizes the affected part forcibly and obtains by the pressure some 
relief. In some instances, however, a certain amount of redness 
and tenderness is present during the paroxysms of the pain, and 
in exceedingly rare cases trophic eruptions occur. The peculi- 
arity of the pains of locomotor ataxia is sufficient to enable us to 
recognize their character, even when other symptoms of the af- 
fection are not perceptible, although the diagnosis cannot be con- 
sidered as positively established until the loss of the knee-jerk, 
or some other symptom of the disorder, is developed. The pains 
are always bilateral, are not increased by motion, and are not 
accompanied by a persistent soreness of the part. If there be 
any tenderness, it is only during or immediately after the pains. 
Wandering gouty pains sometimes simulate the pains of loco- 
motor ataxia, but are never so severe or so persistent, unless there 
be a gouty neuritis, which will be at once revealed by the per- 
sistent tenderness. Moreover, the shooting gouty pain is always 
associated with other marked evidences of the diathesis. 

Although bilateral, a moving pain, accompanied with tender- 



EXALTATIONS OF SENSIBILITY. 293 

ness of the nerve-trunks, with pain on motion, passive or active, 
is never the direct outcome of a disease of the spinal cord. It 
may be a symptom of a descending neuritis due to an involve- 
ment of the nerve-roots in diseases of the spinal membranes. 
Moreover, there is much evidence to show that descending neuritis 
occurs in certain diseases of the spinal cord itself. Under such 
circumstances tenderness of the nerve-trunks is naturally to be 
expected ; but it must be remembered that such tenderness does 
not develop until late in the disorder, and then only in rare cases. 
In various diseases of the nerve-centres, contractures, especially 
in lateral sclerosis, may exist, and the attempt at forcible exten- 
sion of the limb may give rise to pain. This pain, however, 
must not be looked upon as the result of hypersensibility of the 
affected muscles, but as similar to that which would be caused by 
attempting to stretch beyond its normal length a muscle which 
has not undergone contractures. 

TRUNKAL PAINS. 

Reflex Pains. — Many diseases of the muscles, membranes, or 
viscera of the trunk are accompanied by pain. A discussion of 
such pains lies without the province of the present work, but it 
may not be improper to say a few words in regard to certain of 
them which are reflex in origin, and which, although due to local 
disease of viscera, are situated at such a distance from the point 
of organic alteration that they are liable to be mistaken for pure 
nervous or neuralgic pains. The most important of these reflex 
pains are those produced in the shoulders or in the back by dis- 
eases of the liver or of the stomach. A peculiar fixed pain in the 
upper portion of the right shoulder is a not very uncommon symp- 
tom in congestions and other diseases of the liver. The pain of 
gastric ulceration is usually referred to the back, between the 
scapulae. I have known it to be in the lumbar region, and occa- 
sionally it is high up in the shoulders. I have seen the abdominal 
pain which is produced by the escape of a meal into the abdominal 
cavity through a sudden perforation of the gastric wall entirely 
masked by a horrible mortal agony, referred by the patient to the 
top of the left shoulder, and, what seems most extraordinary, 
markedly increased by movements of the body. At the height 
of the agony any alteration of posture produced a violent, excru- 



294 DIAGNOSTIC NEUROLOGY. 

dating spasm of the scapulary and dorso-cervical muscles. In 
this case the ulcer was not suspected during life. 

Rheumatic Pains. — It seems hardly necessary to say much 
concerning rheumatic pains in the muscles of the trunk, but it 
is perhaps proper to call attention to the fact that sometimes 
they are excessively severe, and appear with such abruptness that 
they may be supposed to be the result of traumatism. They 
are always accompanied by excessive pain on motion, and can 
scarcely be mistaken for other idiopathic affections. 

Pains of Chronic Fibrous Inflammation. — A form of back-pain 
which is not infrequent as the result of injury is a persistent 
aching, with a marked and pronounced sense of weakness of the 
part, and sometimes stiffness and pain on movement. This con- 
dition, which may last for years, is, I believe, not a nerve-pain, 
but is due to a very slow chronic inflammation of the fibrous 
tissues which bind together the vertebrae. It is especially apt to 
be present in the lower portion of the back. 

Toxcemic Pains. — Toxsemic pains, due either to gout or to 
malaria, are liable to attack any portion of the body. They may 
locate themselves in the neighborhood of the kidneys, and under 
these circumstances closely simulate the pains of renal colic. They 
can usually be distinguished by their not being so severe or so per- 
sistent, and by their not shooting into the genital organs. Not 
much aid in the diagnosis can be obtained from an examination 
of the urine, since crystals are often not present in the urine in 
cases of renal calculi, and the elimination of uric acid often ac- 
companies the gouty pain-paroxysm. In a malarial case, a more or 
less regular periodicity will usually betray the nature of the disease. 

Herpetic Pain. — A violent stinging pain shooting along the 
course of the intercostal nerves, or located in irregular spots in the 
front of the body, not rarely precedes, but perhaps more generally 
accompanies, the eruption of herpes zoster. Both the eruption 
and the pain are due to inflammation of the intercostal nerves, in 
most cases of a gouty nature. 

Pain of Vertebral Caries. — A fixed, unaccountable pain in the 
shoulders, or very rarely in the lumbar region, may be the first 
obvious symptom of a commencing spinal caries. I have so fre- 
quently seen this pain of sympathetic inflammation of the nerve- 
roots precede the more manifest symptoms of spinal caries that 



EXALTATIONS OF SENSIBILITY. 295 

I look upon it as a forerunner of very serious disease. If an 
individual be of such age and physical character as to bring an 
attack either of syphilitic or of tubercular disease of the ver- 
tebrae within the range of probability, a fixed, apparently cause- 
less, severe neuralgic pain either in the shoulder or in the front 
lumbar region should be viewed with the greatest suspicion, and 
should lead to the most careful study of the case. 

Girdle Pain. — The girdle sensation, so called, is a feeling as 
though a band were tightly drawn around the body. If really 
present, and not imagined by the patient after the suggestion by 
the physician, it, I believe, always indicates organic disease of 
the spinal cord or of the nerve-roots. When not amounting 
to absolute pain, it is usually due to chronic myelitis or to spinal 
sclerosis. When very severe, it may be caused by inflamma- 
tion of the nerve-roots, due to cancerous, syphilitic, or tubercular 
degenerations of the spinal membrane. In some cases this girdle 
pain instead of being around the body encircles some portions 
of the legs. Under these circumstances it is bilateral and sym- 
metrical. I cannot remember to have seen it lower than the 
garter line. 

Pain-Crises. — The most important, as well as the most severe, 
of all the nerve-pains connected with the human trunk are the 
so-called pain-crises which occur in locomotor ataxia. When 
once established, these crises usually persist through the whole 
course of the affection, but they are frequently among the earliest 
of prodromes, and may by many years precede the more common 
symptoms of the disease. 

In a remarkable case now under my care in the University 
Hospital, in which the symptoms followed an injury to the foot, 
and are apparently the result of an ascending neuritis, moder- 
ately severe gastric pain-crises occur simulating those of locomo- 
tor ataxia. The symptoms in the case are and have been violent 
pain, gradually extending up the leg, and thence to the half of 
the body of the same side, at present very severe in the arm and 
face ; marked tenderness over all the nerve-trunks which are the 
seat of pain ; exaggeration of the patella-reflex upon both sides, 
but more markedly upon the side most affected ; contraction of 
the field of vision, with atrophy of the nerve much more pro- 
nounced in the eye upon the affected side ; failure of strength of 



296 DIAGNOSTIC NEUROLOGY. 

the affected leg, with some contractions of the muscles and pain 
on stretching the foot; distinct atrophy of the muscles of the 
affected leg, with modal changes in their electric contractility; 
upon the diseased side great coldness of the foot and lower leg, 
with a somewhat similar condition in the forearm. 

A pain-crisis consists in its essential parts of a paroxysm of 
pain as violent as human nature can endure, accompanied by 
excessive functional disorder of the part attacked, developing 
usually with great rapidity, but disappearing as rapidly as it ap- 
peared, and associated with a condition of undisturbed functional 
activity of the affected viscus between the paroxysms. The crisis 
raay at first return only at long intervals, but as the disease pro- 
gresses it comes on more frequently, and often more severely, 
until at last in some paroxysms syncope alone brings relief. 
During the paroxysm there is no fever ; but the patient is often 
left in a condition of profound exhaustion. 

The most important of the pain-crises are the muscular, the 
gastric, the visceral, the rectal, the urinary, the genital, the car- 
diac, and the laryngeal. 

The muscular pain-crises are extremely rare, but have been 
described in two cases by Dr. Pitres {Prog. Med., July 12, 1884). 
They consist of a feeling of lassitude, deepening into an excessive 
muscular weariness and soreness like that which follows violent 
exercise in one unaccustomed to it, and at last entirely paralyzing 
for the time being the affected muscles. They appear to attack 
more usually the lumbar group, and to make it impossible for tjie 
patient to assume an erect position. They are said to last from a 
few hours to many days. 

The gastric crises appear to be the most frequent of any of 
the pain-paroxysms of locomotor ataxia. They are characterized 
by violent pains having their focus in the epigastric region and 
radiating in all directions, laterally, upward, and downward, 
until at times they seem to fill with agony the whole abdomen 
and chest. The pains are sometimes spoken of as constrictive, 
more usually shooting like a dagger-thrust ; not rarely they are 
burning. They are generally increased by the ingestion of food, 
and are always accompanied by nausea and excessive vomiting 
and the rejection of everything that is put into the stomach. 
The vomiting is repeated many times an hour, and is accom- 



EXALTATIONS OF SENSIBILITY. 297 

panied by horribly distressing retching. After the stomach has 
been emptied, glairy or ropy mucus is ejected: this soon be- 
comes greenish from the presence of bile; and in severe cases 
streaks of blood appear in the mucus : more rarely there is abun- 
dant coflPee-ground vomiting or even pronounced hsematemesis. 
(See case, Vulpian, Maladies du Systeme nerveiix, vol. i. p. 267.) 
In some cases the focus of the pain is in the neighborhood of 
the umbilicus, when the crisis might properly be spoken of as 
intestinal. Occasionally large quantities of gas form in the gastro- 
intestinal tract, and produce a very obstinate meteorism, which is 
itself more or less painful, and is scarcely diminished by the in- 
cessant discharge of gas by the mouth or rectum. This paroxysm 
of atrocious suffering may last from one to a few hours, or even 
for days, interrupted, it may be, by syncope, and finally leaving 
the patient in a condition of profound collapse. It is sometimes 
accompanied by a hypersesthesia of the epigastric region so exces- 
sive that the mere contact of the hand will provoke violent pains. 
During the attack it is absolutely impossible for the patient to 
take food, but usually the paroxysm ends abruptly, and food is 
immediately desired and is digested without diflSculty. When 
the force of the paroxysm expends itself upon the stomach there 
is no disturbance of the bowels, but if enteralgia be severe there 
is usually with it an abundant discharge of bilious or mucous or 
serous stools. In such cases the patient may assume the facies of 
cholera, the likeness being made complete by the loss of the voice, 
the suppression of urine, the extreme coldness and cyanosis of 
the body, and even the presence of cramps. Vulpian reports a 
case of death during such a paroxysm. 

The gastric or gastro-intestinal crisis is distinguished from 
similar attacks due to disease of the stomach or the bowels, by 
the suddenness of its development ; by the excessive severity of 
the symptoms; by the absence of tha ordinary signs of organic 
disease of the stomach or intestines ; by the abruptness of the 
termination of the paroxysm ; and by the complete performance 
of the normal functions between the attacks. It might be sim- 
ulated by hysterical gastralgia with vomiting, but in the latter 
disease the symptoms are not so severe as in the crisis, and are 
attended by globus hystericus, great emotional disturbance, con- 
vulsive movements, anaesthesias, or other well-recognized symp- 



298 DIAGNOSTIC NEUROLOGY. 

toms of hysteria. The occurrence of haematemesis in gastric crisis 
must always suggest the presence of gastric ulcer, but between 
the paroxysms the symptoms of such ulcer ought to be apparent 
if the lesion really exist. 

Much more rarely than the stomach are other abdominal vis- 
cera the seat of pain-crises in locomotor ataxia. In some cases 
true rectal crises occur, with violent pains of a cutting, shooting, 
burning character radiating from the rectum in every direction. 
Not rarely the patient complains bitterly of a sensation as though 
the rectum were filled up by an enormous body heated to red- 
ness, burning and scorching every part near it. (See Trousseau.) 
Among the most painful of these abdominal crises are those 
connected with the urinarif organs. The symptoms may re- 
semble so closely those of renal colic as to make the immediate 
diagnosis almost impossible. Thus (M. Raynaud, Arch, Gen. 
de Med.y October, 1876), a man attacked in the streets of Paris 
w^as brought to the hospital bent double, suffering from a furious 
pain in the belly radiating into the lumbar region along the tract 
of the ureters, and accompanied by retraction of the testicle. An 
incorrect diagnosis of renal colic was at first niade. More fre- 
quently the pains are in the urethra, where they manifest them- 
selves as intense burning, or as lancinating darts of agony shoot- 
ing through the whole length of the urethra and simulating the 
pain of calculus. Usually at the same time there is great distress 
in the bladder, and an incessant desire to pass urine, with tlie 
emission of only small quantities with great straining and with- 
out relief. These pains in some cases occur in paroxysms similar 
to those of the gastric crisis ; in others they are more persistent, 
so that the patient suffers from almost constant distress. Under 
these circumstances there mav be anaesthesia of the ureter and of 
the bladder, with consequent retention of urine and ammoniacal 
fermentation. In some of these cases the urine becomes loaded 
with phosphate, and the mistaken diagnosis of phosphatic calculus 
might be readily made. 

Genital Crises, — Genital disturbance is almost universally 
present in locomotor ataxia. Usually it takes the form of loss of 
functional power. It is in my experience very infrequent for this 
depression to be preceded by sexual excitement, but Trousseau re- 
lates the case of a man in whom the first symptoms of the disorder 



EXALTATIONS OF SENSIBILITY. 299 

were excessive lust, and a strange power of repeating coitus a 
great number of times in rapid succession. Associated with such 
sexual excitement is usually excessive quickness of emission 
during the act, — a quickness which augments until it amounts to 
a veritable spermatorrhoea, the semen being discharged upon the 
slightest provocation, and a true impotence resulting. 

In rare cases veritable genital crises occur. These are of two 
characters. In one, violent paroxysms of pain centre in the testi- 
cles and shoot along the penis to its head, or, in the female, burn 
and bore in the ovaries, the labia minora, and the clitoris. In 
these paroxysms the agony is only a little less than that of the 
gastric crisis. In other cases spontaneous venereal orgasms re- 
place the pain-paroxysm, either in the male or the female. Thus, 
in a case reported by Prof. A. Pitres, a woman suffered with fre- 
quent paroxysms, commencing with a sense of vibration in the 
vagina, followed at once by erection of the clitoris, voluptuous 
sensation, and rapid orgasm. The venereal crises often occurred 
four or five times in the twenty-four hours. After the lapse of 
four years they became associated with fulgurant pains. Four 
years later a gastric crisis occurred, and the other symptoms of 
locomotor ataxia slowly developed. The close connection between 
the venereal and pain paroxysms was shown by the fact that in 
the later years a violent attack of fulgurant or gastric pains was 
always ushered in by an erotic crisis. In another case reported 
by Pitres the venereal paroxysms preceded the fulgurant pains 
by ten years. 

Laryngeal Crises. — The laryngeal crisis is a very rare phe- 
nomenon in locomotor ataxia. Briefly spoken of in 1862 by M. 
Bourdon, it has been fully described by M. F6r6ol {Gaz. Hebdom.^ 
February 12, 1869) and by M. Jean (ibid., July 7, 1876). It 
consists of violent paroxysms of coughing, with great laryngeal 
disturbances of respiration, atrocious fulgurant pains in the shoul- 
ders and along the spinal column, and pronounced symptoms of 
asphyxia. The face is red, intensely congested, and finally cya- 
nosed. The cough, furious, hoarse, grating, is rapidly repeated in 
paroxysms, ending in a raucous inspiration like that of whooping- 
cough. The expectoration is of a scanty saliva-like secretion, or 
rarely of little pellets of mucus stained with blood. The partial 
expirations, abrupt and jerky, follow one another with convulsive 



300 DIAGNOSTIC NEUROLOGY. 

haste, to be succeeded by a prolonged blowing inspiration. When 
the paroxysm is severe the dyspnoea is extreme, and the urine and 
faeces may be passed involuntarily. The paroxysms occur sponta- 
neously by day or by night, but are also produced by draughts of 
air, or by the swallowing of hot drinks or food, etc. There is no 
asthmatic dyspnoea between the paroxysms, although a permanent 
emphysema may be produced by the strain of the violent efforts at 
breathing. The attack usually begins and ends abruptly. In the 
case reported by M. Jean, spasm of the muscles of the pharynx 
finally prevented swallow^ing altogether ; asphyxia alternated with 
syncope, until true coma appeared, to end in death. At the au- 
topsy posterior spinal sclerosis was found ; but, as there was also a 
pronounced lesion in the medulla, it remains doubtful how far the 
laryngeal symptoms were the result of the spinal degeneration. 

Cardiac Crises, — In 1879, Vulpian called attention to the fre- 
quency of valvular disease of the heart in locomotor ataxia, and 
his observations have since been confirmed by both German and 
French writers. Insufficiency of the aortic valve appears to be 
the most frequent lesion ; but Grasset shows by a report upon 
twenty- four cases that the heart-lesions are various. This is con- 
firmed by A. Jaubert (Th^se, Paris, No. 137, 1881), who further 
makes it plain that not only the valves but also the heart-walls 
may be affected. 

It is at present uncertain whether the cardiac lesions are due 
directly to the disease of the nerve-centres, or whether both the 
nervous and the cardiac affections are the result of a common cause. 
That the changes in the heart are not trophic or parallel to those 
which occur in the joints of the ataxic is strongly indicated by 
the fact that in a number of Grasset's cases the cervical spinal 
cord was not implicated. The close connection between syphilis 
and locomotor ataxia on the one hand, and between syphilis 
and arterial degenerations on the other, suggests that the two 
diseases are frequently the result of a common cause. In many 
cases the cardiac affection comes on very insidiously, and symp- 
toms may not appear until long after serious lesions have been 
developed : therefore the practitioner should habitually auscult the 
heart in cases of posterior spinal sclerosis. In some cases violent 
cardiac crises occur. It is uncertain whether they are always asso- 
ciated with lesion either of the heart-valves or of the heart-walls. 



EXALTATIONS OF SENSIBILITY. 301 

They have been present when there were no sufficient physical 
signs to justify the diagnosis of cardiac lesion, and it is therefore 
probable that a cardiac crisis may represent a nerve-storm similar 
to that of a gastric crisis. Charcot has noticed that there is often, 
if not always, a permanent acceleration of the pulse in these 
cases. The symptoms of the cardiac crisis are similar to those of 
angina pectoris, — namely, violent pain in the region of the heart, 
associated with great dyspnoea, intense distress, and irregularity of 
the pulse, with or without intermission of the heart-beats. 

HEAD-PAINS. 

The causes of headache are almost innumerable, and to discuss 
them fully would require a volume. I shall therefore confine my 
attention to a consideration of the chief varieties of headache 
not connected with acute disease, such as fevers, pneumonias, etc. 
In treating any individual case of chronic headache, the first 
vital decision is as to the cause of the head-pain. For this reason 
it seems proper in this work to view headache chiefly from an 
etiological stand-point. The character of headache varies exces- 
sively. It is sometimes deep-seated ; sometimes superficial ; some- 
times a distress; sometimes a violent pain; sometimes a heavy 
ache ; sometimes an acute throbbing; now it fills the whole cra- 
nium, again it radiates over the surface, or settles in some one 
point. It is paroxysmal or constant, shifting or fixed. Unfortu- 
nately, the character of the headache varies in different individ- 
uals with the same cause : thus, even the headache which is the 
result of an organic brain-lesion is different in different patients. 
It is impossible to make the diagnosis as to the nature of the head- 
ache from a study of the headache itself: only by a consideration 
of the concomitant symptoms and in many cases by the process of 
exclusion are we able to arrive at an approximately correct view. 
Cases not a few offer themselves in which the nature of the head- 
ache is finally made out only by studying its response to thera- 
peutic agents. Nevertheless, something can often be inferred 
from the seat of the pain and from its character, and therefore 
I shall point out, as far as may be, peculiarities in individual 
headaches. The best arrangement of headaches for clinical study 
that I have been able to formulate is comprised in the following 
scheme : 



302 DIAGNOSTIC NEUROLOGY. 

1. Organic headaches, or those which are due to disease of the 
braiD-membranes or of the brain-substance. 

2. Toxsemic headaches, or those which are due to the circulation 
in the blood of some poison, either engendered within the lx)dy 
or received from without. 

3. Sympathetic headaches, or those which are due to some 
peripheral lesion, which acts apparently through the nervous 
system without the formation of a poison. 

4. Headaches which are not included in the other groups, and 
to which the name of nervous may be given, with the under- 
standing that the title carries no etiological significance. In 
this group are placed many headaches of whose ultimate cause 
we are ignorant. 

Although I have separated these four groups of headaches, it 
must be distinctly understood that no group is characterized by 
a constant peculiarity in the head-pain, and that in the diagnosing 
of an individual case it is often necessary to pass in review all 
the sub-groups, of which I shall speak later. 

It is a matter of the gravest importance that the pain of an 
acute glaucoma shall not be mistaken for headache. The pain, 
which may develop with great suddenness, often centres in the 
eyeball, but may seem to have its chief focus in the supra-orbital 
notch : not rarely it shoots over the forehead and into the cheek 
and temple, reaching even to the occiput, and filling the whole 
side of the head with agony. If, as usually happens, there is 
fever, with severe vomiting, the patient may be thought to be 
suffering from a bilious or malarial attack, and the eye be irre- 
trievably damaged before the true nature of the paroxysm is dis- 
cerned. This can be avoided by paying attention to the following 
points: the eye shows evidences of inflammation in congestion 
and swelling of the conjunctiva and even of the lids; the cornea 
is somewhat misty, presenting the appearance sometimes spoken 
of as " steam iness,^^ and its sensitiveness to the touch of a caraeFs- 
hair pencil is diminished ; the pupil is sluggish, often somewhat 
dilated; on palpating the two eyeballs simultaneously with the 
forefingers, the affected eye is felt to be the harder, and the patient 
often complains of a sense of tension in the ball ; vision is less 
acute in the affected than in the sound eye. In case of doubt 
it is the duty of the practitioner to call in an oculist at once. 



EXALTATIONS OF SENSIBILITY. 303 

Toxcemic Headache. 

The most important varieties of toxsemic headache are malarial, 
rheumatic, gouty, ursemic, diabetic, alcoholic, and caffeinic. 

Malarial Headache. — A headache may occur in a malarial 
subject as a secondary result, produced by the anaemia or by the 
disorder of the gastro-intestinal tract, etc. Such headaches are 
anaemic, gastric, etc., rather than truly malarial. The specific 
malarial headache occurs in paroxysms at more or less regular 
intervals. It almost invariably takes the form of the so-called 
^^brow ague,^^ in which an intense pain rapidly develops at fixed 
hours in the immediate neighborhood of one supra-orbital foramen. 
This pain lasts from five to ten hours, is often of frightful in- 
tensity, and may or may not be associated with fever and sweat 
or other indications of a malarial paroxysm. It is a malarial 
paroxysm w^hich is to be recognized by its form, and especially by 
the regularity of its recurrence and by its rapidly yielding to 
quinine when given in sufficient doses. It must be remembered 
that it is often necessary to administer as much as thirty grains of 
quinine just previous to the expected paroxysm in order to obtain 
distinct relief. 

Rheumatic Headache. — Rheumatic headache is not infre- 
quent. It usually takes the form of heavy aching pain, worse at 
night and on the approach of storms, and accompanied by more 
or less soreness of the scalp : under these circumstances the rheu- 
matic irritation undoubtedly expends itself upon the fibrous tis- 
sue of the scalp. In other cases the pain is severe, sharp, and 
shooting, passing into the jaws or coursing over the forehead : 
such pain is the expression of a rheumatic neuritis affecting the 
branches of the trigeminal nerve. The rheumatic headache may 
be without any characters indicating its nature. In a sculptor 
who was about to abandon his profession on account of excessive 
intractable headaches, I found that the headaches had occurred 
only during the time when the artist was working upon the mod- 
elling in wet clay of a very large composite life-size group, and, 
not being able to make out any other explanation of the head- 
aches, I put the patient on anti-rheumatic treatment, with the 
most satisfactory results. 

Lithsemic Headache. — Lithsemic or gouty headache in its 



304 DIAGNOSTIC NEUROLOGY. 

usual form is dull and heavy, and often worse on rising in the 
mornings. It may, however, be acute, and I have seen it exces- 
sively violent : in one case, for a series of years there were head- 
aches whose cause could not be made out, and whose violence was 
so great as to make life unendurable. Not a day passed without 
them, and much of the time the head-pain was an agony. In 
this case the headaches finally became associated with attacks of 
loss of consciousness, which closely resembled petit mal, so that 
I was led to the diagnosis of an organic lesion of the brain or 
its membranes. Finally, all the small joints of the body and 
many of the large were simultaneously attacked with a furious 
sudden general gout, with enormous deposits and permanent dis- 
ablement. The headaches were greatly relieved by this outbreak, 
but have reappeared from time to time, although the joint-lesions 
have progressed so that the patient is entirely crippled. My 
own belief is that there was originally a gouty thickening of the 
dura mater with deposit, so that the headaches were not simply 
the result of gouty irritation, but were due to a gouty organic 
lesion. 

Ursemic Headache. — The ursemic headache may take almost 
any form, and the diagnosis must be made out by detecting the 
kidney-disease. Some years since, a patient was brought to me 
who was suffering from a unilateral frontal headache, which al- 
ways commenced from one to two hours after rising, and continued 
to grow more intense until the man went to bed, when it dis- 
appeared. Examination of the urine revealed the nature of the 
trouble. In the pre-albuminuric stage of gouty kidney, when 
the heart is somewhat hypertrophied, the vessels more or less 
rigid, and the arterial tension raised, headache is a common symp- 
tom. How far under these circumstances the headache is due to 
retention of matters in the blood which ought to be excreted, 
how far it is the result of the increased arterial tension, how far 
it is gouty in its nature, often cannot be made out. Dr. S. Weir 
Mitchell speaks somewhere of having seen cases in which repeated 
headaches preceded hemiplegia. It seems probable that these 
headaches were either gouty or ursemic, and were only by accident 
associated with the subsequent rupture of a blood-vessel. 

Alcoholic Headache. — Headache is a common symptom in 
chronic alcoholism ; in some cases it may be due to the direct irri- 



EXALTATIONS OF SENSIBILITY. 305 

tation of the brain-membranes by the alcohol ; but usually it 
appears to be secondary to the gastro-intestinal irritation. 

Oaffeinic Headache. — A very common headache is that which 
I have called caffeinic, because it is the result of the excessive use 
of coffee or tea. The subjects of these headaches are almost always 
of neurotic temperament; not rarely they suffer from migraine 
or some form of nervous headache. It must be borne in mind 
that even a small amount of coffee may, in such persons, pro- 
duce disabling head-pains. Overworked seamstresses and sewing- 
women often supply a lack of food and strength by an excessive 
use of tea. Under these circumstances severe cephalalgia and 
other nervous symptoms are certain to occur. There is no method 
of determining in any individual case that the headache is due to 
the use of tea and coffee except by noticing the effect of suspend- 
ing these beverages. Before a decisive result can be considered 
to have been reached, total abstinence must have been enforced 
for at least three weeks, since when the train of morbid symptoms 
has once been set in motion very small amounts of the beverage 
suffice to keep it moving. 

Gastric Headache. — Headache from disorder of the liver is 
frequent. It can hardly be separated from that which is pro- 
duced by gastric derangement, although in some cases the gastric 
headache-pain is evidently reflex, due to irritation of the periph- 
eral nerve-fiJaments in the stomach by exceedingly acid and acrid 
contents. This acid-stomach headache is usually frontal, and is 
often accompanied by sudden blindness and dizziness and acid 
eructations. Its true nature is revealed by the immediate relief 
which is afforded by the use of large doses of aromatic spirits of 
hartshorn. On the other hand, a dull, heavy headache which 
often accompanies indigestion and hepatic torpor is probably the 
result of the absorption or retention of poisonous organic products. 
It is usually frontal, but occasionally is referred to the region 
behind the ears or to the occiput. It may be associated with 
defective vision, giddiness, and great depression of spirits. 

Diabetic Headache. — Headache is not rarely present in dia- 
betes. When it occurs in an advanced stage with great severity 
it is of special importance, because it is frequently prodromic 
of diabetic coma. Under these circumstances it is usually ac- 
companied by dizziness, muscular pains, gastric distress, and dis- 

20 



306 DIAGNOSTIC NEUROLOGY. 

ordered mental action, as shown by incoherent talk or by actual 
delirium. 

Cardiac and Pulmonic Headaches. — Violent headache often 
accompanies diseases of the heart and lungs which are sufficiently 
severe to interfere either with oxidation of the blood or with 
the circulation. In cases of obscure chronic headache, especially 
in children, practitioners should always carefully examine the 
condition of the heart. 

Sympathetic Headaches. 

Pains in the head are in rare instances the result of compara- 
tively distant irritations : thus, there are cases on record in which 
lancing the gums or removing a diseased tooth has relieved a 
severe and perhaps long-existing headache. 

Headaches of Eye-Strain. — Severe headaches frequently re- 
sult from eye-strain. The head-pain is produced by a disorder 
of accommodation, or by an insufficiency of one of the ocular 
muscles. Although very frequently the facts connected with the 
pain are suggestive of its cause, yet the headache of eye strain 
has no fixed determinate character. It is usually frontal or in 
the region of the eye, but this position is not always selected. 
In a case reported by Dr. William Thomson [Med. and Surg, 
Reporter, 1874), the headache finally assumed characters exactly 
simulating those of the most typical migraine, the paroxysms 
commencing with an attack of partial blindness involving half 
the visual field, followed by severe pain in the head lasting many 
hours, accompanied by nausea and great general depression. In 
almost all cases the pain is greatly aggravated by the use of the 
eyes, and in the earlier periods of its history only follows such use ; 
finally it may come on at all times, and often apparently spon- 
taneously. It is apt to be very severe in the mornings after an 
evening spent at the theatre or other place of amusement where 
the lights are very bright. Sometimes the pain is not confined to 
the head, but radiates down the back. The difficulty of diagnosis 
is often aggravated by the fact that the headache of eye-strain 
is especially common in neurotic subjects, and that it not rarely 
coexists with head -pain of other character. The conjunctival 
symptoms, although not constant, are characteristic: they consist 
of chronic irritation, with intense redness and velvety appearance 



EXALTATIONS OF SENSIBILITY. 307 

of the mucous membrane and of the tarsus. Although in many 
cases the symptoms are sufficiently definite to lead to a strong 
suspicion of the cause of the headaches, a positive decision can 
be reached only by a careful examination of the eye by the ocu- 
list, and the counteraction of any defects that may be found. 

Nasal Headache. — Headaches may be the result of disease 
of the nasal mucous membrane. Prof. Harrison Allen concludes 
that there are three kinds of these nasal head-pains, which he 
denominates respectively the reflex, the neurotic, and the inflam- 
matory. The reflex headache is almost entirely restricted to the 
forehead, the temple, and the vertex. By drawing the index 
finger across the face from the middle of the nose to the temple, 
and thence in some cases to the parietal eminence, the patient 
often indicates the seat of the pain. In severe attacks pain some- 
times radiates to the vertex and even to the nape of the neck, 
and then often nauseates and simulates migraine. Sometimes the 
point of pain is narrowed to a minute focus or spot. A very 
characteristic symptom is the marked increase of the headache 
upon the slightest exacerbation of the catarrh. A diagnostic 
symptom is tenderness of the inner wall of the orbit when pressed 
upon by the finger ; or a probe passed into the nose causes an 
immediate access of pain when it reaches the right middle turbi- 
nate bone. The disappearance of the catarrhal reflex headache 
when the nasal catarrh is cured is the strongest proof of its na- 
ture. The neurotic nasal headache of Prof. Harrison Allen com- 
prises cases in which highly neurotic individuals complain of vio- 
lent pain in the throat, the ears, the back of the head, or even the 
pharynx, or of various distresses about the head, as a result of a 
moderate degree of local nasal or pharyngeal disease. Dr. Allen 
further says that he has never seen catarrhal headaches of inflam- 
matory origin except in acute congestion or inflammations of the 
frontal sinuses : the pain is of high grade, is as a rule confined to 
one side, and subsides after the local application of leeches. 

Nervous Headache, 

Under the title of nervous headache I shall group the so- 
called anaemic headache, congestive headache, the headache of 
brain- exhaustion, the hysterical headache, migraine, and certain 



308 DIAGNOSTIC NEUROLOGY. 

rare headaches whose nature is completely obscure, but which may 
be designated by the misnomer of idiopathic headache. 

Anseraic Headache. — The headache which is seen in those 
who are suffering from well-marked anaemia following malaria, 
bleeding piles, etc., has in itself nothing that is peculiar or char- 
acteristic. It is often brought on or aggravated by use of the 
brain, and in this way is related to the headache of brain- 
exhaustion. Very frequently during the attack the face will 
flush and the eyes redden, and the patient complains of a sense 
of fulness in the head. In these symptoms the headache resem- 
bles the congestive headache. As in many other of these forms 
of headache, the diagnosis is to be made out by discovering the 
existence of the disease or condition which produces the head- 
ache, and by the relief which follows the cure of the parent 
affection. The headache which is sometimes associated with fatty 
heart is probably due to an improper supply of blood to the 
brain, and may properly be considered to be a variety of anaemic 
headache. It must be borne in mind, however, that palpitation 
of the heart and cardialgic disturbance may be prominent symp- 
toms in anaemia, and mislead the diagnostician into supposing 
that a cardiac lesion exists. 

Congestive Headache. — Congestive headaches, or headaches 
from active hyperaemia, are, I think, extremely rare, unless after 
exposure to the sun or some other immediate exciting cause. 
They are to be distinguished by the severity of the throbbing 
pain, by the sense of pressure and weight in the head, by the 
suffusion in the face and eyes, and by the strong pulsation in the 
carotid. The pulse is usually full and strong, and the cephalic 
symptoms may go on to the appearance of hallucinations, and even 
to the production of coma or delirium. 

Hysterical Headache. — In many cases of hysteria the patient 
suffers much from violent pains in the head, of varied character. 

Almost characteristic of the temperament is the so-called davus, 
a pain situated in the middle of the top of the head in a point so 
small that it can almost be covered with the point of the finger. 
The hysterical headache is apt to be increased at the men- 
strual period, and to be suddenly removed by pleasurable mental 
excitement. 

Headache of Exhaustion. — In exhaustion of the general 



EXALTATIONS OF SENSIBILITY. 309 

nervous system, from such generally acting causes as severe con- 
joined mental and bodily exertion, nursing, depressing emotions, 
sexual excesses, etc., or in the limited exhaustion of the brain- 
centres from excessive intellectual work, the patient commonly 
suffers from a sense of weight at the top of the vertex, or from 
a heavy, dull, oppressive, deep-seated cephalic distress. This 
form of headache is often associated with insomnia, and is always 
increased by any intellectual effort. 

Mi^aine. — Under the name of migraine, or megrim, are in- 
cluded very numerous cases, which, while they have much in 
common, vary greatly in the development of their symptoms. 
The essential feature of the affection is a paroxysmal headache, 
which in the great majority of cases appears first at early puberty 
and continues in women up to the menopause, or in men to 
advanced middle life. In its details the paroxysm varies in 
different individuals, but usually conforms more or less to the fol- 
lowing type. For some hours before the attack the patient suffers 
from malaise, often with chilliness and a sense of languor, or in 
rare cases experiences a condition of peculiar emotional and mental 
activity. The attack may or may not be ushered in by distinct 
prodromes. The pain is unilateral in the great majority of cases, 
and is referred to the frontal region, having the focus at or about 
the supra-orbital foramen, or more rarely in the eye itself. It 
comes on gradually, becoming more and more intense for hours, 
until finally it is unbearable. It is generally described as boring 
in character, often throbbing, and only in very rare instances as 
shooting into the jaws and the neck. Sometimes the occipital 
region may be the seat of the pain. About the time that the pain 
reaches its greatest intensity, nausea followed by vomiting de- 
velops. The vomiting is usually repeated, and is attended with 
great bodily depression. The matters ejected are the contents of 
the stomach, followed by mucus and bile. Apparent relief often 
follows the vomiting. In some cases the patient now falls asleep, 
and wakes free from the headache ; in other cases the headache 
gradually subsides. The whole paroxysm lasts from five hours 
to two or even three days. During the height of the attack of 
migraine there is generally intolerance of light and sound ; and 
yet, according to E. Souila {Thdse, Paris, 1884, No. 35), occasion- 
ally there is an intense craving for light, and even for noise. 



310 DIAGNOSTIC NEUROLOGY. 

Although the general features of an attack of migraine conform 
to the account just given, there are certain symptoms which are 
occasionally present, and demand more detailed description. In 
some cases the prodromes are very marked, and include distinct 
disturbance of a special sense. The sight is the most frequently 
affected, and next after it the smell. Possibly a peculiar bitter 
taste in the mouth which seems frequently to precede an attack 
of migraine, and which is generally referred by most patients to 
disorder of the stomach, should be noted as among the sensory 
prodromes. This taste has seemed to me to be closely connected 
with a peculiar, excessively disagreeable odor of the breath, which 
in turn appears to be due to the excretion of some sulphuretted 
compounds. Jewelry about the person may be very distinctly 
tarnished during an attack. 

More usual and more distinctly prodromic is the phenomenon 
which M. Galezewski has described under the head of migraine 
ophthalmica^ or hemiopia periodica. The most frequent form of 
this is an amblyopia, accompanied by vivid scintillations passing 
zigzag, like the lines of a fortification, over the field of vision. 
When hemiopia occurs, it may be either monocular or binocular; 
sometimes it is lateral ; in other cases it occupies the superior half 
of the visual field. In the binocular form a lateral half of the 
field is attacked. The vision is completely abolished in the 
affected portion of the field, although the total acuity of vision 
may remain normal. This sensory disturbance very rarely occurs 
except in persons who have long suffered from the migraine. In 
some cases it is preceded by headache, but usually it develops 
suddenly as the beginning of the paroxysm ; occasionally instead 
of hemiopia a central scotoma is the dominant symptom. Rarely 
this scotoma merges itself finally in a hemiopia. In rare cases 
these disturbances of sight are replaced by distinct visions or hallu- 
cinations. The olfactory disturbance which ushers in a migraine 
is generally of a peculiar odor, like that of osmic acid, etc. The 
auditory prodrome has been variously described as like the sound 
which is produced when a marine shell is applied to the ear, or as 
a gurgling similar to that which is heard when water enters the 
ear during washing. It is stated that in very rare cases a taste 
comparable to that produced by passing an electric current through 
the mouth is prodromic of a paroxysm of migraine. 



EXALTATIONS OF SENSIBILITY. 311 

The psychical symptoms which accompany a migraine are usu- 
ally not severe ; but in rare cases they are very marked, affecting 
especially the emotional nature, causing in one instance profound 
melancholy and depression, in another, vivacity; in either case 
there is commonly an excessive irritability. During the attack, 
according to the measurements of O. Berger, there is a condition 
of hypersesthesia of the skin of the face, at least so far as the sense 
of locality and the electric sensibility are concerned. Certainly 
in most cases there is no excessive sensibility to pressure, and 
indeed commonly the pain is more or less distinctly relieved by 
firm pressure. There is usually no tenderness either during or 
after the attack at the point of emergence of the nerve from the 
bone, although in some cases a certain degree of general tender- 
ness of the face is produced by a violent paroxysm. A remark- 
able but very rare complication of migraine is an aphasia during 
the height of the attack. Thus, in a case reported {Gazette des 
Hdpitaux, May 17, 1884) by Prof. Charcot, there was habitu- 
ally complete aphasia for about an hour during the crisis of the 
paroxysms. 

As the affection has come under my notice in this country, 
vaso-motor disturbance is not usually pronounced ; but Eulenburg 
distinguishes two varieties of migraine which he says are typical. 
In the one, during the height of the paroxysm, upon the affected 
side the face is pale, the pupil dilated, the temporal artery hard, 
and the temperature of the external auditory canal is reduced 
one to two degrees Fahr. Pressure of the carotid upon the 
side of the pain now increases the pain, whilst pressure upon 
the artery on the opposite side of the neck tends to relieve it. 
Towards the end of the paroxysm the face and ear become red, 
with a sensation of heat and an absolute rise of the temperature ; 
at the same time there is in some cases a contraction of the pupil. 
In the second variety of migraine described by Eulenburg there 
are throughout the paroxysm evidences of vaso-motor depression. 
Always at the height of the attack the face is red and hot, the 
conjunctiva injected, and the lachrymal secretion increased. The 
ear of the affected side is distinctly hotter than its fellow, and the 
sweat is very abundant at the immediate site of the pain, or some- 
times the sweating is unilateral. By compression of the carotid 
upon the affected side the pain is lessened, but it is increased by 



312 DIAGNOSTIC NEUROLOGY. 

pressure upon the artery of the opposite side. It is affirmed that 
in some cases the dilatation of the arteries and veins can be 
detected in the fundus. Towards the close of the attack the face 
becomes pale. 

The existence of these varieties of migraine I have not been able 
to verify. A very extraordinary phenomenon which is vouched 
for by the late Dr. Anstie, of London, is that in certain cases of 
migraine an absolute change in the color of the hair of the eye- 
brows in the immediate neighborhood of the pain can be seen to 
occur during the paroxysm, the hair becoming white, but regain- 
ing its color after the pain-storm is past: by a succession of these 
paroxysms the hair is gradually bleached permanently, so that 
a white lock appears in the eyebrow or even in the head. 

The peculiar features of a paroxysm of migraine are usually 
repeated in the next, the same type of attack being persistent in 
the one individual. 

There have been a number of theories brought forward as 
explanatory of the attack of migraine. As these theories still 
remain theories, it is beyond the province of the present work to 
discuss them. Clinical experience shows, first, that migraine is 
in some way related to gout; secondly, that in the great majority 
of cases it is an inherited disorder, which has close relations with 
other serious neurotic ailments. 

Face-Pahis, 

Probably owing to its great development and to its exposed 
position, the trigeminal nerve is especially prone to suffer from 
functional and organic disturbance. The sensory root arises from 
a nucleus near the floor of the fourth ventricle, and emerges from 
the pons to enter quickly the Gasserian ganglion, which it leaves 
in three branches, the ophthalmic, the superior maxillary, and the 
inferior maxillary. The first of these furnishes branches to the 
eyeball, to the lachrymal gland, to the mucous membranes of 
the nose and eyelids, to the skin of the nose, upper eyelid, and 
forehead, and to the upper part of the hairy scalp. The superior 
maxillary nerve supplies the integument above and over the 
maxillary bone, that of the lower eyelid, that of the side of the 
nose and upper lip^ also the upper teeth, the mucous membranes 
of the nose, of the upper part of the pharynx, of the antrum, 



EXALTATIONS OF SENSIBILITY. 313 

and of the posterior ethmoidal cell ; it also sends its branches to 
the soft palate, the tonsil, the uvula, and the glandular and mu- 
cous structures of the roof of the mouth. The inferior maxil- 
lary nerve supplies the lower jaw and teeth, the tongue, the mu- 
cous membrane of the mouth, and the salivary glands, and sends 
filaments to the side of the head, the external ear, the external 
auditory canal, the lower lip, and the lower part of the face. 

Much has already been said in this book in regard to pain- 
storms which affect the trigeminal nerve. In addition to these 
we must recognize four classes of pain in the nerve : 

First Neuralgic. 

Second. Reflex. 

Third. Neuritic. 

Fourth. Prosopalgic. 

By neuralgia affecting the trigeminal nerve is meant violent 
pain occurring in the nerve which is not due to any known 
organic affection, and which is simply an expression of a gen- 
eral neuralgic temperament, either hereditary or acquired. By 
most authors the term neuralgic in regard to the trigeminal nerve 
is given a very much wider significance, so that almost any form 
of trigeminal pain is spoken of as neuralgic. Trigeminal neu- 
ralgia, using the term in its restricted sense, is to be recognized 
by the coexistence of the neuralgic temperament, and by the 
absence, between the paroxysms, of the tender points of neuritis. 
(See page 314.) The neuralgic temperament is itself to be made 
out by knowing the history of repeated attacks of pain, affecting 
now this, now that region of the body, — inconstant, shifting, ap- 
parently causeless. These pains are the expression of a general 
neurotic vice. 

Reflex trigeminal pains are the result of some more or less 
permanent irritation situated at a distance from the nerve, and, it 
may be, in a position having no direct connection with the nerve. 
These reflex pains usually do not have the history of long con- 
tinuance that is characteristic of dental and prosopalgic pains. 
They are also usually much less severe ; but they are especially to 
be recognized by the discovery of a point of irritation, and by 
the removal of the irritant. They have been noted as following 
injuries to distant nerves, as due to the irritations produced by 
lumbricoids or tapeworms, and to over-excitation of the uterine, 



314 DIAGNOSTIC NEUROLOGY. 

ovarian, or other organs of generation, as well as to hsemor- 
rhoids and other rectal diseases. 

Trigeminal neuritis is a very frequent affection. In a large 
proportion of cases it is gouty or rheumatic. The pain is violent, 
affecting perhaps the whole distribution of the nerves, certainly 
a large territory, and usually associated with a distinct history of 
rheumatism in the past or with other evidences of a general dis- 
order in the present. Trigeminal neuritis may be suddenly pro- 
duced by excessive exposure. It may, under these circumstances, 
be rheumatic; but it seems to me probable that there is a non- 
rheumatic neuritis directly caused by exposure. A very important 
form of trigeminal neuritis is that which is produced by decayed 
teeth, through the propagation of an inflammation of the pulp 
along the smaller twigs until the w^hole nerve is involved. Of 
similar nature to such neuritis is that which has been described 
by Prof. Gross as a peculiar neuralgia occurring in the toothless 
remains of the alveolar processes of old people, and due to the 
irregular or excessive deposits compressing and irritating the 
nerves. Dental neuritis is essentially chronic, is associated with 
horrible suffering, and when once established has little or no ten- 
dency to get well, although in the earlier stages it maybe arrested 
by removing the point of irritation, — that is, the affected tooth. 
A neuritis arising from a decayed tooth is usually confined 
throughout its course, or at least for many months, to the inferior 
or superior maxillary branch ; and such isolation of a neuritis 
should always give rise to a suspicion of dental origin. 

Trigeminal neuritis is to be distinguished from neuralgia of 
the nerve by the persistent tenderness felt at the point of emer- 
gence of the nerves from the bones of the face. As these points 
were first pointed out by Dr. F. L. I. Valleix, they are frequently 
spoken of as Valleix's points. 

In the ophthalmic branch, the most important point is the 
supra-orbital foramen. Less commonly to be recognized are the 
palpebral points of the upper eyelid, the nasal on the nose, where 
the ethmoidal nerve emerges from the nasal cartilage, the inner 
angle of the eye, corresponding to the supra-trochlear nerve, and 
the parietal prominence. In the superior maxillary branch, the 
most important point is over the infra-orbital foramen ; next in 
order is that in the upper lip, then those in the gums or in the 



EXALTATIONS OF SENSIBILITY. 315 

alveolar processes of the upper jaw. In the inferior maxillary 
branch, the point on the chin is the most frequent, next is one 
in front of the ear, while very inconstant and rarer are points 
on the lower lip, on the side of the tongue, and on the alveolar 
processes of the lower jaw. 

Under the term prosopalgia I include all trigeminal pains 
which are neither neuralgic, reflex, nor neuritic. The suffering 
in prosopalgia is apt to be intolerable; pains of the most furious 
character shoot w^ith lightning-like rapidity along the course of 
the nerves, follow one another in incessant flashes for a few 
seconds or minutes, and then abruptly cease. In many cases these 
pains are accompanied by furious clonic and tonic contractions of 
the muscles of the side of the face, giving rise to the congeries 
of symptoms known as tic-douloureux. In some cases paroxysms 
occur only a few times a day, but more frequently they repeat 
themselves at short intervals. The lower jaw and cheek are 
probably the most frequent seats of the pain ; somewhat more 
rarely are the branches of the upper maxillary and even of the 
ophthalmic nerves affected. Only in exceptional cases do the 
mucous membranes suffer ; but frightful burning, shooting, sting- 
ing, darting pains may be felt in the mouth, and become exces- 
sively severe as they run through the tongue. Often, impelled by 
an irresistible impulse to do something, or perhaps led by a slight 
feeling of relief, the patient, during the paroxysms, incessantly 
rubs the affected part with the hand, either naked or armed with 
a handkerchief, and it is not uncommon under these circumstances 
to see the cheek bare of skin from incessant rubbing. These 
severer forms of prosopalgia are capable of being arranged in two 
groups, — those in which a lesion can and those in which it cannot 
be demonstrated. I have seen a violent trigeminal ancesthesia 
dolorosa immediately follow an apoplexy, and due, without reason- 
able doubt, to the involvement of the sensory nucleus or fibres of 
the trigeminal nerve in the pons. Cruveilhier found a cancerous 
growth attacking the nerve-sheath in a case of obstinate proso- 
palgia. Laveran noted a fibrous degeneration of the Gasserian 
ganglion; Lippic, caries of the bone immediately below the out- 
going nerve-root; and syphilitic, cystic, and gliomatous tumors 
have been found in the neighborhood of the Gasserian ganglion. 
A progressive lesion running a not too rapid course and involving 



316 DIAGNOSTIC NEUROLOGY, 

the sensory roots or nucleus of the trigeminal nerve, either before 
or after they enter the Gasserian ganglion, is often the cause of 
an obscure prosopalgia. To cases of prosopalgia without obvious 
lesion Prof. Trousseau gave the name of epileptiform neuralgia, 
because of his belief that the affection is related to epilepsy. 
This opinion was founded on his having seen disorder of the intel- 
ligence in some cases, and having noted in others that the attacks 
were ushered in by vertigo or other aura-like sensation, whilst 
one or two epileptics suffering from violent prosopalgia had come 
under his notice. Obstinate, apparently causeless prosopalgia 
occurs especially in old people : it is probable that it is the result 
of atrophic or nutritive degenerations of the nuclei or of the root 
of the nerve, such degenerations often being caused by alterations 
of the walls of the blood-vessels. I can see no sufficient reason 
for believing that a paroxysm of tic-douloureux ever represents 
one of idiopathic epilepsy. 



CHAPTER VIII. 

DISTURBANCES OP THE SPECIAL SENSES. 

HEAEING. 

For testing the hearing the neurologist usually relies upon the 
ordinary watch or a tuning-fork. In many cases the acuteness of 
audition is to be determined by comparing the two ears of the 
patient. If both sides are equally aflFected, it becomes necessary to 
compare the hearing of the individual with that of another person. 
The varying loudness of the ticking of watches and the great natu- 
ral differences in the acuteness of hearing in different individuals 
render an accurate estimation of the amount of a double deafness 
difficult. There is an instrument known as the tonometer, used by 
otologists, which is supposed to give always a sound of a definite 
intensity ; but it is probable that even this instrument as made by 
different instrument-makers varies in the intensity of its sound. 
Moreover, I know of no studies in which the range of normal 
audition has been determined : so that the ordinary practitioner is 
usually forced to take his own hearing as the normal standard. 

In examining a case of deafness the neurologist must first 
determine whether the existing deafness is due to disease of the 
middle ear or is neurotic. In doing this it is customary to em- 
ploy the tuning-fork. If the deafness be unilateral and be due 
to obstructive disease, either of the middle or of the internal ear, 
when a tuning-fork in vibration is placed upon the vertex the 
noise is heard much more intensely in the deaf ear. Under such 
circumstances the neurologist knows that the loss of hearing is, at 
least in part, due to wax in the external meatus, stoppage of the 
Eustachian tubes, or other obstructive disease. Unfortunately, in 
certain middle-ear diseases, such as anchylosis of the bones, the 
tuning-fork is not heard more loudly on the deaf side. As, how- 
ever, these cases are comparatively rare, it is a general rule that 
when the tuning-fork is not heard more loudly on the deaf side 
the deafness is probably due to a lesion of the nerve itself or of its 
centre. We have no way of determining with certainty whether 

317 



318 DIAGNOSTIC NEUROLOGY. 

such loss of hearing is due to a lesion in the labyrinth, in the 
trunk of the nerve^ or in the nerve-centres : labyrinthine disease 
is, however, generally connected with severe giddiness, whilst in 
disease of the nerve or of its centre giddiness, if it exist, is not 
severe. 

The eighth, or auditory, nerve has its principal nucleus in the 
floor of the fourth ventricle, close to the nuclei of the vagus, the 
glosso-pharyngeal, and the hypoglossal nerves. From this nucleus 
the inferior root arises. The second, outer, superior, or minor 
auditory nucleus lies between the inner nucleus and the restiform 
body, and gives origin to the superior root of the nerve. The 
roots pass obliquely outward and unite into a single trunk, which 
appears at the lower edge of the pons on the outer side of, and 
close to, the facial nerve. After leaving the medulla oblongata 
the nerve is directed outward, in company with the facial nerve, 
to the internal auditory meatus. 

Deafness from disease of the auditory nuclei is very rare. 
Peripheral neurotic deafness is much more common. The audi- 
tory nerve is liable to be pressed upon by syphilitic, tubercular, or 
other exudations at the base of the brain, and is especially exposed 
to paralysis from disease of the mastoid processes of the temporal 
bone. It may therefore be laid down as a general diagnostic rule, 
the exceptions to which are very rare, that a nervous deafness not 
associated with marked giddiness is dependent upon a lesion of the 
nerve-trunk. 

Hypersesthesia of the auditory nerve produces a loss of hearing 
which is characterized by excessive susceptibility to sounds. The 
normal stimuli of the nerve produce pain rather than normal 
functional excitement, so that, although unable to perceive minute 
difiFerences in sounds, the patient suffers acutely from loud noises. 

SIGHT. 

In discussing the relation of the eye to diseases of the nervous 
system, I shall take up first its movements, next alterations of 
the pupils, and then internal conditions. 

MOVEMENTS OF THE EYE. 

Strabismus. — When one or more of the eye-muscles are par- 
alyzed or excessively contracted, the axis of the eye is drawn 



DISTURBANCES OF THE SPECIAL SENSES. 319 

out of its normal direction^ — in the one case by the sound mus- 
cles, which are no longer controlled by their normal antagonists; 
in the other case by the overacting muscle or muscles. When 
from any cause the axes of the eyes do not correspond, the patient 
is said to suffer from strabismus, or squint. A strabismus may 
be either paralytic or concomitant. Paralytic strabismus is almost 
invariably the result of disease of the nervous system ; concomi- 
tant strabismus is the outcome* of an ocular defect. In the 
hypermetropic eye the squint is usually convergent; in the 
myopic or near-sighted eye it is usually divergent. 

In any individual case the first point in the diagnosis is to de- 
termine whether the existing squint is paralytic or concomitant. 
The diagnosis as to which muscle is affected is to be made by 
studying, — first, the movements of the eye ; secondly, the so-called 
secondary deviation ; thirdly, the absence or presence of double 
vision, and, as part of this, the false projection of the field of 
vision of the paralyzed eye. 

First With the patient sitting before him, the practitioner 
holds up the finger or the point of a pencil and requires the sub- 
ject to follow its movements with the eye, the head being kept 
still. Under these circumstances, if the squint be paralytic the 
movements of the ball will be found to be restricted on the side 
of the paralyzed muscle. This test seems a very simple one, but, 
owing to the complicated relations of the ocular muscles, in some 
cases judgment is difficult. 

Secondly. It is well known that one eye habitually follows the 
movements of the other eye, so that if the left eye be directed 
towards an object situated on the extreme left the right eye fol- 
lows it even though covered. The movements of the second eye 
depend upon the fact that when a nerve-centre is called upon to 
move one eye it sends an equal and parallel amount of force to 
the other eye: thus, if the external rectus and associated muscles 
be called upon in one eye, the internal rectus and associated muscles 
in the other eye receive an equal amount of nerve-force. W^hen 
a partially paralyzed muscle is required to turn the eye in a certain 
direction up to a certain amount, it is plain that a much greater 

* The explanation of the connection between ocular defects and strabismus 
belongs to works on diseases of the eye, as it is a purely local matter. 



320 DIAGNOSTIC NEUROLOGY. 

exertion on the part of the nerve-centre controlling the movement 
will be required to produce the desired movement than would 
be necessary if the muscle were not paralyzed. The amount of 
nerve-force discharged from the centres being equal in the two 
eyes, it follows under the circumstances just spoken of that the 
muscle of the normal eye will receive a greater amount of nerve- 
force than is necessary to carry the eyeball over the required dis- 
tance : the eye will, therefore, be drawn beyond the object which 
is to be looked at. If, after such movement, the normal eye be 
directed towards the object, the ball will have to return towards 
its central position, — the amount of return being exactly the excess 
of movement first produced. This return is the measure of the 
" secondary deviation/^ — the secondary deviation being the distance 
which the sound eye has been drawn beyond the position which 
it normally should have assumed. Primary deviation is the de- 
viation of the eye whose muscle is paralyzed, from its normal 
position, when the object is looked at with the sound eye. 

To make this matter clearer, let us suppose that x represents the 
amount of force required to move the normal left eye a given 
distance towards the left, and that the muscles of the left eye 
become so far paralyzed that 2.r is required to execute the necessary 
movement. When such movement is executed, the sound eye will 
receive 2a; instead of x nerve-force, and will therefore be drawn 
twice as far from its central position as is required. The second- 
ary deviation will therefore be the amount of movement which 
is produced by the expenditure of x force in the eye. In order 
to make clear the method of testing the presence of secondary 
deviation, let us suppose the patient has a defect in the left eye. 
The right or sound eye is covered with the hand or a piece of 
paper, w^iilst the left or aflFected eye is directed towards an object 
situated at the distance of a few feet. When the left eye has 
been focussed upon such an object, the patient is told to look at it 
with the right eye, and the cover hastily removed : the right or 
sound eye will now be seen to move in a direction opposite to that 
towards which the paralyzed muscle draws the ball. Thus, if it 
be the external rectus of the left eye that is affected, the right 
eye when uncovered will move backward towards the right, 
because its internal rectus has originally received an excess of 
nerve-force and drawn it too far towards the left. 



DISTURBANCES OF THE SPECIAL SENSES. 321 

Thirdly, If by pressure upon the ball the axis of one eye is dis- 
torted, two objects are seen, because the visual fields of the eyes 
no longer correspond. Double vision is equally produced when 
the distortion of the axes is the result of a paralysis and when it 
is caused by an overaction of one or more muscles. When the 
lesion of the muscle and consequent distortion of the axes has 
been very gradually developed, the patient as gradually loses the 
perception of one of the two images, or, in other words, habitu- 
ally sees with only one eye. The concomitant squints due to 
defects of the eye are very slowly developed, so that the second 
image is habitually lost and the patient has conscious vision only 
of the single object. On the other hand, paralytic squints are 
usually suddenly or rapidly developed, and the habit of not heed- 
ing one image has not time to form itself, so that double vision 
results. For these reasons we are able to frame the diagnostic rule 
that whilst a paralytie squint is almost invariably accompanied by 
doable vision^ a concomitant squint is rarely so accompanied. In 
most of the cases in which the second image has been lost through 
habit it can be developed by placing a colored glass before the 
sound eye, so as to tint one of the images. When the images are 
so near together that they overlap, the result is a blurred image, 
which by the colpred glass is resolved into two. 

Double vision may be crossed or simple. Crossed diplopia 
occurs in cases of divergent squint: the image seen by the left eye 
is to the right of that seen by the right eye. In other words, 
the image seen by the left eye is carried beyond or crossed over 
that seen by the right eye. Simple or homonymous diplopia 
exists in convergent squint. In it the image seen by the left 
eye is to the left of the other image. A great aid to the memory 
in regard to this diplopia is afforded by remembering the rule laid 
down by Gowers in his lectures, — namely, that when the pro- 
longed axes of the eyes would cross, the images are not crossed; 
whilst when the prolonged axes would not cross, the images are 
crossed. In other words, convergent squint causes simple diplo- 
pia, divergent squint causes crossed diplopia. 

In long-existing cases of paralytic squint, secondary contractures 
of the non-paralyzed muscle may give rise to diplopia of peculiar 
character. For the discussion of these finer points the reader is 
referred to works upon the eye. 

21 



322 DIAGNOSTIC NEUROLOGY. 

The false projection of the visual field is a subject which seems at 
first very abstruse, but which may readily be simplified. According 
to my thinking, it really is neither more nor less than diplopia, 
although Gowers speaks of it as though it were a distinct symp- 
tom. We judge of the positions of objects in regard to our own 
body by their relations to our visual fields. This relation depends 
upon the position of the head and of the eyes, so that the degree 
of contraction of the muscles of the head and of the eyes — i.e., 
the amount of nerve-force which is given off to them — uncon- 
sciously becomes to our consciousness a measure of the position 
of objects. If the muscles of the eye are at rest, the ball is in 
mid-position, and we know that an object upon which we are 
focussing the eye, or, in other words, at which we are intently 
looking, is directly in front of the face ; that is, w^e know that a 
line drawn from the centre of the object at which we are looking 
to the centre of the field of vision — i.e,, to the visual centre of 
the retina — would be at right angles to the face. If the eye is 
now focussed upon an object to the left, the degree of movement 
of the eye — that is, the amount of nerve-force given to the mus- 
cles of the eye — is the basis of the unconscious judgment which 
leads to the recognition of the position of the object relative to 
our own bodies. Experience has shown us that the expenditure 
of X force on the appropriate muscles in turning the eyes to the 
left is required if the body looked at is situated at a certain angle 
in regard to ourselves. If the object looked at is sufficiently 
close for us to lay our hands upon it, we unconsciously throw into 
the nerves of the arm force which in amount and direction cor- 
responds to that given to the eye-muscle, so that the hand is placed 
directly upon the object seen. If the eye-muscle is partially 
paralyzed, and an increased amount of nerve-force is required to 
produce the necessary contractions of the eye- muscles in looking 
towards the object, the lower nervous system throws into the hand, 
which is put forth to touch the object, force which in amount and 
direction corresponds to the abnormally large force required to 
move the weakened eye-muscle. The hand is therefore projected 
too far to one side of or beyond the object, according as this or that 
ocular muscle is paralyzed. The false direction of the arm will 
accord with the direction of the secondary deviation of the sound 
eye ; that is, if the normal eye goes too far to the left the arm will 



DISTURBANCES OF THE SPECIAL, SENSES. 323 

go too far to the left, etc. The discord which thus arises between 
the face of things as seen and as felt often produces vertigo or 
giddiness : hence the so-called ocular vertigo. (See article on Ver- 
tigo.) In some cases the nerve-centres finally learn to accommo- 
date themselves to the altered circumstances. In other cases the 
patient may try to avoid the vertigo by holding his head in such a 
position that the affected muscles are not called into action, or by 
closing the affected eye, either with the hand or, more generally, 
by a contracture of the orbicular muscle. As pointed out by 
Gowers, the affected eye is always the one closed, because, although 
closing either eye would remove the diplopia, only closure of the 
affected ej^e removes the vertigo or uncertainty, by removing the 
discord between the visual and other sensations. 

This scientific explanation of the false projection of the visual 
field is, of course, interesting, but after all it amounts only to this, 
that the patient sees the image of the object looked at in a false 
position, and that he naturally puts his hand forward to seize the 
image at the position in which he sees it. Thus, if in a case of 
diplopia two distinct inkstands are seen, although only one exists, 
and the secondary inkstand is perceived to the left of the true one, 
when the sound eye is closed the patient sees only the secondary 
or left image. If now, with the sound eye closed, he should at- 
tempt to take hold of the inkstand, he would of course seize, not 
the inkstand proper, but the secondary image which alone he sees. 

Oculo-motor Palsy. — A paralytic divergent squint is due to palsy 
of the third, or oculo-motor, nerve, which supplies all the muscles 
of the orbit except the superior oblique and external rectus. As 
it is possible for certain fibres of the oculo-motor nerve to be 
paralyzed and the remainder to preserve their normal activity, one 
of the muscles supplied by the eye may be alone affected. This 
necessitates a brief consideration of the varieties of strabismus 
connected with each muscle. 

When the internal rectus is paralyzed, there is defect of the in- 
ward movement of the eye, and crossed diplopia, the false image 
being oblique above and below the horizontal plane ; when the 
superior rectus alone is paralyzed, the movement upward and 
outward is affected: a certain amount of upward and inward 
movement is preserved in the ball, because the inferior oblique 
muscle habitually acts with the superior rectus in causing those 



324 DIAGNOSTIC NEUROLOGY. 

movements: double vision occurs on looking upward, the false 
image being above the true. When the inferior rectus muscle 
is paralyzed, there is loss of the downward and outward move- 
ments: the secondary deviation is produced by the opposite 
rectus moving the ball too much downward and outward, so 
that the return movement is upward and inward. This form 
of strabismus is apt to be confounded with that which results 
from paralysis of the superior oblique (fourth nerve: see p. 325). 
Paralysis of the inferior oblique muscle causes defect of the 
upward movements : the secondary deviation is produced by ex- 
cessive action of the inferior oblique and internal rectus muscles 
of the sound eye, so that the ball is carried too much upward 
and inward and the return movement is outward and down- 
ward : double vision occurs with the false image oblique and 
situated above the true, the obliquity being greatest in looking 
outward, the defect in height in looking inward. 

The third, or oculo-motor, nerve emerges from the inner side of 
the crus cerebri close to the upper border of the pons, and extends 
outward and upward between the posterior cerebral and supe- 
rior cerebellar arteries to the outer side of the posterior clinoid 
process, a little anterior to which it penetrates the dura mater 
close to the outer boundary of the cavernous sinus, and passes 
through the sphenoidal fissure. Its deep root is situated in the 
gray matter of the floor of the Sylvian aqueduct, in the region of 
the superior corpora quadrigemina, just above the nucleus of the 
fourth, or trochlear, nerve. The fibres pass forward from the 
nucleus through the tegmentum and the tegmental nucleus, and 
partly through the substantia nigra to the point of emergence. 
Owing to the position of its nucleus, the oculo-motor nerve is 
liable to be paralyzed by lesions of the crus cerebri. Under these 
circumstances the symptoms of the oculo-motor palsy are upon 
the side of the body opposite to the hemiplegia or hemianresthesia. 

As the oculo-motor nerve supplies not only the muscles of the 
eyeball, but also the elevator of the upper eyelid, the levator palpe- 
brae, its complete palsy is foUow^ed by ptosis, paralysis of accom- 
modation, and dilatation of the pupil, as well as by paralysis of the 
muscles of the ball. The discussion of the relations of the oculo- 
motor nerve to the pupil will be found under the head of Pupil. 

Partial paralysis of the oculo-motor nerve has a significance 



DISTURBANCES OF THE SPECIAL SENSES. 325 

Similar to the same phenomenon in the abducens^ with the ex- 
ception, at least in my experience, that functional palsy is more 
rare. Owing to its prolonged course at the base of the skull, 
it is especially liable to be pressed upon by syphilitic or tu- 
bercular exudations. An acute oculo-motor palsy which is not 
rheumatic is in the adult generally syphilitic, and in the child 
usually tubercular. 

According to the statistics of Eulenburg, the oculo-motor nerve 
is more frequently aflFected in locomotor ataxia than are the other 
ocular nerves. Under these circumstances the paralysis is nearly 
always partial; very rarely is there ptosis, usually the muscles 
and the pupils alone being aflPected. On the contrary, it is not 
rare in syphilis for ptosis to exist without marked disorder of the 
pupil or of the muscles of the eyeball. 

Paralysis of Trochlear Nerve. — Loss of movement of the eye 
downward and inward, with the convergent strabismus most 
marked when the patient looks down, is due to the paralysis of 
the superior oblique muscle, which is supplied by the fourth, troch- 
lear, or pathetic nerve. Care may be necessary to distinguish 
paralysis of the superior oblique muscle from that of the inferior 
rectus, in which the loss of movement is down\vard and outward : 
the distinction is readily made by paying attention to the position 
of the images in double vision. In paralysis of the inferior rectus 
the diplopia is crossed, and the false image is placed below the 
true and is oblique. The greater the attempted movement, the 
lower it is situated and the more oblique it is. In paralysis of 
the superior oblique muscle the diplopia is simple, and, the false 
image being lateral, the distance between the two images is greatest 
in the middle line, and lessens when the object is moved inward or 
outward. The diplopia occurs especially when the patient looks 
downward, and often gives much trouble in going down-stairs, 
the patient being unable to distinguish the false from the true 
image of the descending flight. The trochlear or pathetic nerve 
has its superficial origin just below the corpora quadrigemina, and 
is directed at first outward across the superior peduncle of the 
cerebellum, and then turns forward around the outer side of the 
crus cerebri, between the posterior and superior cerebellar arteries. 
Its nucleus is situated between the superior and inferior quadri- 
geminal bodies, immediately below that of the third nerve. A 



326 DIAGNOSTIC NEUROLOGY. 

partial decussation of this nerve is said to occur in the anterior 
medullary velum at the commencement of the aqueduct. Para- 
lytic affections of the trochlear nerve are very rare, but may occur 
under circumstances similar to those of the oculo-motor nerves. 

Paralysis of Abducens Nerve. — Paralytic convergent squint is 
due to paralysis of the external rectus muscle. The outward move- 
ments of the eye are restricted ; the diplopia is simple. The two 
images are parallel and on the same plane when on the horizontal 
plane of the centre of vision, but they are usually more or less 
oblique and on a different plane when they are situated above or 
below the horizontal visual plane, — i.e., when the eye has to be 
moved upward or downward. 

The external rectus is supplied by the abducens, or sixth cranial, 
nerve. This nerve arises in the groove between the pons and the 
medulla oblongata, immediately external to the upper end of the 
pyramid, and, going outward, lies close to the floor of the cavernous 
sinus, in contact with the outer side of the internal carotid artery; 
finally it passes through the sphenoidal fissure to the muscle. Its 
deep root is situated in the floor of the fourth ventricle ; a few fibres 
are believed to pass upward and across the raphe to join the third 
nerve of the opposite side. In this is to be found the explanation 
of a few recorded cases in which atrophy of the nucleus of the 
sixth, or abducens, nerve has been followed by paralysis of the 
internal rectus of one side and the external rectus of the other 
side, — i.e., by a convergent squint on the side of the lesion and 
a divergent squint on the opposite side. 

Partial paralysis of the external rectus not rarely occurs from 
simple neurasthenia, especially when the cerebral exhaustion is 
largely manifested by disorder of vision. In such cases, and also 
in cases of locomotor ataxia with strabismus, double vision from 
disorder of the optic axis may occur although the strabismus is 
not sufficient to be easily noticeable. Paralysis of the external 
rectus, as of other eye-muscles, may be rheumatic. In such cases 
there is usually a history of exposure, pain in the eyeball or its 
neighborhood, swelling and pain in the face, and various evi- 
dences of a rheumatic diathesis. Attempts to move the eyeball 
also cause pain. 

A complete, non-rheumatic paralysis of the abducens nerve 
always depends upon an organic lesion either of the nerve itself 



DISTURBANCES OF THE SPECIAL SENSES. 827 

or of its centre. In cases of tubercular or syphilitic basal meningitis 
the nerve is very apt to be pressed upon ; and it may be laid down 
as a sufficiently accurate rule that aeute^ complete, non-rheumatic 
paralysis of the external rectus in the child is tubercular or syphilitic, 
in the adult syphilitic, unless due to cerebrospinal meningitis. 

In certain cases of poliomyelitis the nucleus of the abducens 
undergoes wasting, and the muscle suffers from atrophic palsy. A 
convergent strabismus from paralysis of the sixth nerve is also an 
occasional phenomenon in posterior sclerosis. It was present in six 
of the twenty-five cases of locomotor ataxia with strabismus recorded 
by Eulenburg. This form of convergence is, like all other forms 
of strabismus due to locomotor ataxia, apt to occur at first in parox- 
ysms — i,e,,io come and go — and to be associated with giddiness. It 
may be a very early phenomenon, preceding the more pronounced 
symptoms of posterior sclerosis. When the sclerosis commences 
high up, strabismus, atrophy of the optic disk, and fulgurant 
pains in the distribution of the fifth nerve may long precede the 
usual symptoms of locomotor ataxia. (See Clozier, Recueil d^Oph- 
thalmologie, 1880, ii.; also Galezowski, ibid., 1884, vi. 334.) 
Paralysis of eye-muscles, with or without alterations of the pupils, 
is somewhat common in multiple sclerosis, having been noted in 
thirteen of the fifty cases observed by R. Gnauck {Neurolog. Cen- 
tralblatt, 1884, iii. 314). In some cases of sclerosis nystagmus is 
present. 

Ophthalmopleg'ia Interna. — Under the name of ophthalmo- 
plegia interna Mr. Jonathan Hutchinson describes {Med.-Chir. 
Trans., vol. Ixi. p. 215) an affection of the eye which he believes 
to be the result of paralysis of the ciliary ganglion. In this gan- 
glion the fibres of the.oculo-motor nerve meet with those nerve- 
fibres which, originally springing from the cilio-spinal axis of the 
cervical cord, pass upward through the superior cervical sympa- 
thetic ganglion to the brain. From the ciliary ganglion the con- 
joined sympathetic and oculo-motor fibres pass outward to supply 
all muscular fibres within the eyeball. Destruction of the ciliary 
ganglion is consequently followed by iridoplegia, or paralysis of 
the iris, both as to the circular and the radiating fibres, and by 
cyclojolegia, or paralysis of the ciliary muscle. I have never 
recognized a case of ophthalmoplegia interna, and I think there 
is difficulty in its positive diagnosis. Unfortunately, I have not 



328 DIAGNOSTIC NEUROLOGY. 

been able to find in any of the various papers of Mr. Hutchinson 
upon this subject a solution of the difficulties. Either the oculo- 
motor nerve, which supplies the circular fibres of the pupil, or 
the sympathetic nerve, which supplies the radiating fibres, may be 
separately paralyzed, or the two may be conjointly paralyzed. In 
either case the pupil is immovable to light or other influence. 
When the oculo-motor nerve alone is paralyzed, the pupil is 
dilated. When the sympathetic nerve alone is affected, the pupil 
is contracted. When both nerves are paralyzed, the pupil must 
be of medium size. The degree of dilatation in the oculo-motor 
palsy varies, however, greatly, and I strongly suspect that some 
of the recorded cases of ophthalmoplegia interna were simply 
instances of oculo-motor paralysis. 

Ophthalmoplegia Externa. — Ophthalmoplegia externa is a 
name applied by Mr. Hutchinson {Med.-Chir, Trans., vol. Ixii.) 
to those cases in which all tlie external muscles of the two 
eyes are more or less completely paralyzed. Long before the 
name was given by Mr. Hutchinson the condition was described 
by Von Graefe as ophthalmoplegia pvogrefisiva. If the palsy is 
nearly complete, there is marked drooping of the upper lid, with 
complete immobility of the eyeballs, giving rise to a very pecu- 
liar expression of the face. Usually the internal muscles of {\\q 
eye are also implicated, but occasionally, according to Mr. Hut- 
chinson, they escape. The causes of the affection are various. 
Paralysis of all the muscles of a single eye is in the majority of 
cases due to pressure upon the nerves at the base of the brain : 
in adults such pressure is usually caused by syphilitic exudation. 
A double ocular paralysis may evidently be caused by a syphilitic 
or other growth of such size and situation as to press upon the 
nerves of both eyes. Ophthalmoplegia externa may, however, 
be of centric origin. A case is reported by Mr. Hutchinson in 
which, at the autopsy, was found degeneration of the nuclei of 
the affected nerves apparently identical with that which occurs 
in progressive muscular atrophy. Dr. Thomas Buzzard [Brainy 
vol. V. p. 34) has recorded the case of a syphilitic woman in 
whom ophthalmoplegia externa coexisted with symptoms of loco- 
motor ataxia, and in whom there was found, after death, degener- 
ation of the nuclei of the ocular muscles and of some portion of 
the gray matter of the cord, and also pronounced posterior scle- 



DISTURBANCES OF THE SPECIAL SENSES. 329 

rosis. According to Dr. Edward Nettleship (Diseases of the Eye, 
Philadelphia, 1883, p. 392), in young adults a functional oph- 
thalmoplegia externa sometimes develops, with symptoms which 
come on quickly and pass off completely; in some cases there are 
repeated attacks. 

Associated Paralysis of the Eye.* — In certain cases there 
is paralysis of the eye-muscles which are associated with one an- 
other in their movements. Thus, the vertical movement may be 
lost in each eye. In such a case the obvious explanation offers 
itself that the nuclei of the affected nerves are symmetrically 
diseased. When, however, the associated paralysis involves the 
lateral movements of the eye, the muscles which are implicated 
are not supplied by the same nerves. Thus, in the left eye there 
would be loss of power in the external rectus muscle, whilst 
in the right eye the internal rectus would be affected. In such 
a case a post-mortem examination by M. F6r6ol demonstrated the 
lesion to be situated on the level of the eminentia teres and to 
affect the nucleus of the sixth pair, which is joined by a band 
of fibres with the oculo-motor nucleus of the other side. (See 
page 87.) Associated paralysis of the eye is asserted to be 
frequent in multiple cerebro-spinal sclerosis (Parinaud, Progres 
Medical, xii. 641); but as that disease occurs in this country it 
must be a very rare complication, since I have never seen it. 

Conjugated Deviation of Head and Eyes. 

As long ago as 1834, M. Andral, in the third edition of his 
Clinical Medicine, called attention to a symptom occasionally oc- 
curring in apoplexy which has recently been much commented 
upon.f In ordinary hediiplegia the tendency of the head is to fall 
passively towards the paralyzed side, but in certain cases the head 

* For an elaborate paper on this subject by H. Parinaud, see Archives de 
Neurologic^ vol. v. p. 145. 

t The reader desirous of following up this subject will find most of the 
references up to the date of its publication in the monograph by Dr. J. L. 
Prevost, De la Deviation conjugee des Yeux, et de la Rotation de la Tete dans 
ceriains Cas d^ Hemiplegie. Since that date the papers of Dr. Broadbent 
{London Lancet, vol. ii., 1879, p. 861), Dr. Landouzy {Progres Medical, 1879, 
vol. vii. p. 957), and Dr. Bechterew {St. Petershicrger Medicin. Wocheiischrift, 
March 14, 1881) are the most important on the subject. 



330 DIAGNOSTIC NEUROLOGY. 

is drawn forcibly from the paralyzed extremities, and the eyes 
with their axes parallel are also forcibly directed towards the sound 
limbs. This so-called conjugated deviation of the head and eyes 
varies in intensity. The spasm of the aflFected muscles is some- 
times so intense that it is almost impossible to restore the head to 
its normal position. Usually, however, the head can be i)ut back, 
but returns to its abnormal posture the instant the force is with- 
drawn. In milder cases it may be very easy to restore the head, 
and no immediate movement may follow letting it go, but slowly 
the head returns to its original position. When consciousness 
coexists with this symptom, except in very mild cases, the patient 
has no control over the head and eyes. 

Conjugated deviation of the head and eyes is much more apt 
to develop when the hemiplegia comes on suddenly ; and in severe 
cases of apoplexy, when all the limbs are so flaccid that it may be 
difficult to discover the existence of the local palsy, the diagnosis 
of cerebral hemorrhage may occasionally be made out by noting 
the distorted position of the head and eyes. It is true that in the 
beginning of an epileptic convulsion drawing of the head and 
eyes may occur, but it lasts only for a minute or two. Jacksonian 
epilepsy often begins with conjugated deviation, and when the con- 
vulsive seizures follow one another very closely the spasm of the 
neck- and eye-muscles may be persistent (Bechterew). 

The pupil may be drawn into the canthus of the eye. Ordinarily 
the balls are entirely quiet; but marked nystagmus is not very 
rare. Conjugated deviation is commonly fugitive. It may cease 
immediately after the development of the full apoplectic symp- 
toms, but it commonly disappears in a few hours, or at most in a 
few days. In fatal cases it is not uncommon to see it cease just 
before death. This fugitive character is not, however, universal, 
for in some recorded cases the distortion has persisted for a month 
or more, or even for a whole year. Occasionally during an attack 
of apoplexy the deviation of the eyes and head may return after 
having disappeared, or the symptom may be first developed in 
the midst of the apoplectic storm : under these circumstances it 
marks the renewal of the hemorrhage. 

Although in the majority of instances the face and eyes are di- 
rected away from the paralyzed side and towards the lesion, there 
are exceptional cases which are not at present readily explained. 



DISTURBANCES OF THE SPECIAL SENSES. 331 

Among the cases collected by Prevost there are three in which the 
direction of the head was towards the paralyzed side. In each of 
these cases the lesion was in the peduncle of either the cerebrum 
or the cerebellum. On the other hand, in a similar case reported 
by Dr. Bernhart {Vtrchoio^s Arehiv, vol. Ixix.) the lesion was a 
very large meningeal hemorrhage, and in the reported case by 
Dr. Nothnagel [Diagnos. der Gehirnkrankheiten, p. 682) it was a 
softening in the cortical motor zone. These exceptional cases 
Avould seem to show that the law formulated by Vulpianand Pre- 
vost, that in lesions of the hemisphere the head is drawn towards 
the lesion and away from the paralysis, whilst in lesions of the 
mesencephalon it is drawn away from the lesion and towards the 
paralysis, has exceptions. According to Dr. Landouzy, when there 
are unilateral convulsions with conjugated deviation, if the head 
and eyes look towards the convulsed extremities there is an irri- 
tative lesion of the hemisphere, but if the head is turned away 
from the convulsed limbs the irritative lesion is in the mesen- 
cephalon. 

INTERNAL OCULAR CONDITIONS. 

The internal conditions of the eye which it is necessary to study 
in their relations to the nervous system are — first, alterations of 
the optic disk, or end of the optic nerve ; secondly, alterations in 
tlie retinal power of receiving impression. 

ABNORMALITIES OF THE DISK. 

Five years after the discovery of the ophthalmoscope Von 
Graefe called attention to the marked alterations in the intra- 
ocular ends of the optic nerve which frequently occur in intra- 
cranial disease. Of these alterations he described two main 
varieties, — the one in which there is intense swelling of the 
intraocular end of the nerve, and the other in which there is 
a dull suffusion of the disk. To the first of these he gave the 
name of stasis papillce. It is now generally known as " choked 
disk.^^ The second he designated as descending neuritis. 

In choked disk the end of the optic nerve projects into the 
eye as a small protuberance or umbonation. Its height may be 
equal to its own diameter. Through its oedematous and opaque 
nerve-fibres run the tortuous, enlarged, and sometimes newly- 



332 DIAGNOSTIC NEUROLOGY. 

formed ocular vessels, which hide the arteries and allow only 
the branches of the tortuous and dilated retinal veins to be seen 
sloping down from the swollen papilla to their normal level in 
the retina. In descending neuritis the disk is slightly swollen, 
dull red, with an opacity of its nerve-fibres which completely 
hides its normal boundaries. The tortuous veins and arteries 
are often diminished in size.* 

Typical cases of choked disk and descending neuritis, seen at 
the height of the disorders, are said to be distinguishable, but 
usually they shade off so imperceptibly one into the other, and 
terminate in atrophies which present so absolutely the same ap- 
pearance, that it is impossible to distinguish between them. 

Choked disk in most cases develops slowly, requiring from a 
few days to a month to attain its maximum. After this it may 
remain unchanged for a year, or even more. Ordinarily, however, 
atrophy begins in the course of a few months. It is remarkable 
how nearly perfect vision may be even when the disk is enor- 
mously swollen; but when atrophy is fairly established almost 
invariably the amblyopia becomes apparent. In the diagnosis 
of neuritis some care on the part of the beginner is necessary not 
to mistake for descending neuritis the neuro-retinitis due to eye- 
strain from incorrect visual defects or from local congestion from 
other causes. 

Von Graefe explained the choked disk by supposing that the 
returned blood in the cerebral sinuses is dammed up by the gross 
lesion of the brain and causes an impeded circulation with in- 
creased blood-pressure in the ophthalmic vein and its branches^ — 
the effect of this damming back being increased by the rigid tissue 
of the lamina cribrosa acting like a multiplier and increasing the 
pressure at the head of the nerve. This theory of Von Graefe, 
however ingenious, has been abandoned by ophthalmologists in 
favor of one or the other of two theories. The first and the least 
probable of these is that the choked disk is due to paralysis of 
the vaso-motor nerves connected with the blood-supply in the 

•^ The author acknowledges his especial indebtedness to the able articles 
by Prof. "William Norris (" Medical Ophthalmology," in the 5tli vol. of the 
System of Practical Medicine^ by America7i Authors^ Philadelphia, 1886) and 
Prof. E. C. Seguin (" Hemianopsia," Journal of Nervous and Mental Dis- 
eases, January, 1886). 



DISTURBANCES OF THE SPECIAL SENSES. 333 

pupil. The second is the so-called lymph-space theory. As 
shown by the anatomical researches of Schwalbe, Retzius, and later 
anatomists, the sheaths of the optic nerves communicate freely 
with the pia mater and the arachnoid spaces of the brain, which 
are in turn portions of the lymphatic system of the cerebrum. 
When, therefore, owing to a gross lesion, the lymphatics of the 
brain become choked, there is an excessive pressure upon all the 
lymphatic spaces, which especially expresses itself in the lymph- 
spaces of the optic disk, a free, unsupported portion of the 
system. 

The latter view is confirmed by experiments upon the lower 
animals and upon the human cadaver, and also by a large num- 
ber of autopsies, which have showm that choking of the disk has 
been accompanied by dilatation of the outer sheath of the nerve 
by lymph, pus, or blood which has found its way down from the 
cranial cavity. It has also been proved that growths in contact 
with the distal end of the nerves may produce choked disk by 
causing a local accumulation of fluid. The fact that in certain 
cases of choked disk no distinct lymph-lesions have been found 
after death is explained by the supposition that such dilatation of 
the vessels has disappeared in the secondary inflammations and 
degenerations which have been set up. 

Whatever theories we may adopt to explain the production 
of choked disk and of optic neuritis, clinical experience shows 
that double choked disk is generally dependent upon brain- 
tumor, abscess, meningitis, or other gross lesion, and that de- 
scending neuritis may be produced by a basal meningitis. For 
practical purposes we may consider the two lesions as identical, 
although if in any case a typical descending neuritis is found the 
probabilities are in favor of the existence of a basal meningitis 
rather than of any other forui of gross brain-lesion. A basal 
meningitis may, however, produce a typical choked disk. One 
disk may occasionally be affected earlier than the other. Under 
these circumstances the lesion is usually on the side of the nerv-e 
first attacked. A double optic neuritis sometimes occurs in ad- 
vanced Bright's disease. It is probable that in such cases there 
is always serous effusion into the subarachnoid space of the brain, 
or, in other words, that there is gross lesion of the brain. It 
has already been stated that tumors and other diseases far back 



334 DIAGNOSTIC NEUROLOGY. 

in the orbit may produce a choked disk^ such choked disk being 
usually unilateral. If a choked disk be unilateral it is probably 
due to local disease : nevertheless it may be the outcome of a 
coarse brain-lesion. 

Although in a great majority of cases optic neuritis is the 
result of gross cerebral disease, it may be a primary affection, 
following typhus, typhoid, scarlet fever, measles, variola, and 
other constitutional diseases. There is also a form of it which is 
rheumatic, or at least is directly produced by exposure. It may 
also develop without discoverable cause, as in a case which I 
watched for many months without being able to detect any evi- 
dences of rheumatism or of cerebral or kidney disease. Sudden 
blindness, with neuritis, is said to have been produced by the 
arrest of menstruation by exposure, and to have been recovered 
from by the restoration of the flow. For details of this and other 
cases the reader is referred to the paper by Dr. H. F. Hansell 
(Medical News, vol. xlix. p. 144). This idiopathic or rheumatic 
optic neuritis is frequently monocular. 

The absence of choked disk does not prove the non-existence 
of gross brain-lesion. In a case under my care the eyes were 
examined two days before death by one of our most eminent 
ophthalmologists, and the nerve pronounced absolutely healthy : 
yet a large tumor of the frontal lobe was found at the au- 
topsy. This is in accord with the general experience that lesions 
of the frontal lobe are especially apt not to give rise to changes 
in the optic papilla. Gowers believes that disk-changes occur 
in eighty per cent, of all cases of cerebral tumors. In a series 
of eighty-eight cases quoted by Norris, the disk was altered in 
ninety-three per cent. Hughlings Jackson calls attention to 
the fact that optic neuritis is essentially a transient symptom, 
which often occurs early in the disease, but may be developed 
only in the last weeks before death. A slowly-growing tumor or 
exudation w^hich does not affect the optic chiasm or the optic 
nerves may remain for months or years without causing an optic 
neuritis, because it does not materially increase the pressure upon 
the brain or set up inflammation of the lymphatics. When the 
alterations of the brain are rapidly progressive, or when they 
are accompanied by much irritation, infiltration of its nerve and 
sheath with lymph or inflammatory products must rapidly ensue. 



DISTURBANCES OF THE SPECIAL SENSES. 335 

When a cerebral tumor presses upon the intra-cranial portion of 
the optic nerves^ or when the chiasm is compressed and atro- 
phied by the protuberant and bulging floor of the third ventricle, 
as in cases reported by Foerster, optic atrophy may occur without 
precedent choked disk. 

Atrophy of the Optic Papilla, 

Atrophy of the optic papilla may be produced by choked disk, 
by certain diseases of the cerebro-spinal axis, especially sclerosis, 
and by affections of the eye itself. 

After a choked disk has continued for a greater or less length 
of time, the swelling begins to subside and the reddish tint to pass 
slowly into a dull, opaque, grayish-white color. The peculiar 
oedematous look of the papilla also fades into a faintly-clouded 
appearance. The outline slowly becomes somewhat more sharply 
defined, but may remain obscure, passing insensibly into a faintly- 
clouded retina until the papilla has returned to nearly its normal 
level. The changes continue to progress; the disk becomes con- 
tinually whiter, with more sharply defined outlines, until at last 
it is of a dead-white color, with hard margins which look as 
though cut by a punch, and with both arteries and veins atrophied. 
The retinal veins change much more slowly than do the arteries, 
and may remain dilated and tortuous even when the atrophy is 
considerably advanced. 

Atrophy of the optic nerve may result from a lesion of the 
optic centres, or from pressure upon the optic nerve-trunk, chiasm, 
or tracts, as by a tumor, an injury, a local inflammation, or a 
distention of the third ventricle. Even meningitis may produce 
atrophy, in rare instances, without antecedent intraocular inflam- 
mation. These atrophies are white or gray. When gray, the tint 
may closely resemble that which is supposed to be more or less 
characteristic of sclerotic spinal disease. Primary atrophy not in- 
frequently appears without known cause. Sometimes it is heredi- 
tary : in one instance it affected all the males of a family. Such 
cases have been studied by Leber, and more recently by W. F. 
Norris {Trans. Amer. Ophthalmol, Soc, 1884). 

The atrophy of the optic nerve which accompanies sclerotic 
conditions of the nerve-centres is not preceded by any stage of 



336 DIAGNOSTIC NEUROLOGY. 

swelling or of demonstrable inflammation. The normal grayish- 
pink tint of the disk begins to change into a peculiar bhiish 
or bluish-green color, and at the same time the transparency of 
the disk diminishes, so that the retinal vessels are less readily 
traced into the substance of the papilla. As the atrophy progresses, 
the discoloration of the papilla gets more marked and its size may 
appear to be diminished; the outline grows continually harder 
and more sharply defined, and the choroidal border becomes ex- 
cessively distinct, while within it the scleral ring grows unnatu- 
rally distinct and whiter than the adjacent nerve. The blood- 
vessels may diminish in size, the small ones upon the disk 
disappearing entirely. But such changes take place very slowly; 
and only in rare cases is there sensible lessening in the size of 
either the main arteries or veins. On the other hand, in other 
atrophies the arteries become very narrow, and at last are reduced 
to minute threads, and the veins slowly diminish in calibre. 
Greenish atrophy is developed so gradually, and the changes 
which it produces in the nerve are at first so slight, that its early 
recognition may be a matter of great doubt. To illustrate the 
difBculties of the situation, I may say that I once sent a patient 
to two of the best ophthalmologists of the country, and received 
absolutely antagonistic opinions. 

Atrophy of the papilla from central nervous affections is ac- 
companied by contraction of the field of vision, and the discussion 
of the diseases in which it occurs is deferred until the considera- 
tion of that symptom. 

PUPILS. 

In the examination of the pupils the first point to be attended 
to is their size. The norm of pupillary enlargement varies almost 
indefinitely in different individuals, so that it is impossible to 
detect slight departures from health. A pupil which is abnor- 
mally contracted is said to be myotic^ the condition of contraction 
being known as myosis. The corresponding terms for enlarge- 
ment of the pupils are mydriatic and mydriasis. Froui the ad- 
jectives myotic and mydriatic are formed the terms myotics and 
mydriatics, denoting classes of drugs which produce correspond- 
ing changes in the pupil. 

Inequality of the pupils is of great diagnostic importance to 



DISTUKBANCES OF THE SPECIAL SENSES. 337 

the neurologist, although it is occasionally present in normal eyes. 
I have also seen mistakes arise from one pupil being accidentally 
under the influence of a drug. The inequality of the pupils may 
be due to an excessive contraction or an excessive dilatation of 
one pupil. Which of these factors is the cause of the alteration 
is to be judged of by comparing the size of the pupils with that 
of the pupils of other persons. Excessive mobility of the pupil, 
a constant to-and-fro play without obvious cause, is an indica- 
tion of nervous weakness, and especially of that kind of nervous 
mobility which is associated with hysteria. It is also seen in cer- 
tain persons with a transparent, fine skin w^ho are predisposed to 
tuberculosis. 

The normal pupil contracts rapidly on exposure to light, and 
dilates with equal rapidity when the stimulus of the light is 
removed. When the eye is directed from a near to a distant 
object the normal pupil dilates, this dilatation being an asso- 
ciated movement with accommodation. Pinching the skin of 
the neck causes dilatation of the pupil, a phenomenon which is 
known as the skin pupillary i^eflex. A very peculiar series of 
pupillary phenomena is that which was first pointed out by 
Dr. Argyll Robertson as occurring in locomotor ataxia. In the 
Argyll Robertson pupil there is no movement when the skin of 
the neck is pinched, and no contraction or dilatation with the 
varying intensities of light, but the relations between the pupil 
and accommodation are preserved. In other words, a pupil which 
remains immovable when the skin of the neck is pinched, or 
when light is allowed suddenly to shine into the previously dark- 
ened eye, does move when the gaze of the patient is suddenly 
directed from a near to a distant object. 

Loss of the light-reaction of the pupil when there is no poison 
in the blood nor evidence of cerebral congestion is often looked 
upon as proof of the existence of organic disease of the brain. 
As has, however, been shown by Thomsen {CharitS Annalen^ 
Berlin, 1885), after the epileptic paroxysm the pupil may be 
fixed for many hours, although consciousness has been com- 
pletely recovered. Immobility of the pupil is also occasionally 
present in hysterical states, and, according to the researches of 
Uhthoff (quoted by Thomsen), it occurs in a small percentage 
of those who are insane but not paralyzed. 

22 



338 



DIAGNOSTIC NEUROLOGY. 



The explanation of the various pupillary phenomena is best 
made by means of the following diagram contrived by Erb. 




A, nerve-fibres from the cerebrum. B, optic centre. S, optic nerve. E, pupil. 
F, retina. H, oculo-motor nerve. C, oculo-motor centre. D, ocular centres in the 
cervical spinal cord (cilio-spinal axis of Budge). IK and IL, sympathetic nerves. 

M, N, and N, sensory nerves. 

Myosis. — Excessive contraction of the pupil, or myosis, may be 
due to paralysis of the roots of the sympathetic nerve in the cervical 
spinal region, or of the sympathetic nerve-fibres in the neck ; or 
it may be the result of stimulation of the oculo-motor nerve- 
centres in the brain. In cervical spinal disease, such as pachy- 
meningitis, myelitis, or chronic sclerosis, myosis may occur if the 
lesion is sufficient to paralyze. I have seen excessive unilateral 
myosis due to the pressure exerted upon the sympathetic nerve- 
fibres by enlarged cervical glands. Aneurisms and other tumors 
in the neck may have the same effect. If, in such a case, by the 
interference with circulation in the carotid, any cerebral symptoms 
are produced, or if there is hysteria, a mistake in diagnosis might 
readily be made. 

A spasmodic myosis may be caused by an irritation of the 
oculo-motor centres or nerves. The contracted pupil of opium- 
poisoning and of cerebral congestion is due to centric irritation, 



DISTURBANCES OF THE SPECIAL SENSES. 339 

whilst that caused by Calabar bean is probably produced^ at least 
in part, by a peripheral action. 

Mydriasis. — Mydriasis, or dilatation of the pupil, may be due 
to irritation of the sympathetic, as in inflammatory lesions of the 
cervical spinal cord, but in the majority of cases it is the result of 
a centric or a peripheral paralysis of the oculo-motor nerve. The 
causes of such affections of the nerve have already been sufficiently 
discussed. 

Action to Light. — The presence of the normal relations of the 
pupil to light proves in any case that the arc E C B F (Fig. 21) is 
intact,— i.6., that the optic nerve and tract to the corpora quad- 
rigemina and thence to the oculo-motor nucleus and thence through 
the oculo-motor nerve to the iris are functionally active. It must, 
however, be borne in mind that the two eyes act in association, so 
that contraction of both pupils occurs when light falls upon one 
eye. In this way a blind eye in which the optic nerve is para- 
lyzed may have movements of the pupil. In examining an eye 
it is therefore essential that the other be covered. 

Skin-Refiex. — It is believed that the skin pupillary reflex is 
produced through the spinal region. Thus, the impulse travel- 
ling up the cervical nerves stimulates the cervical spinal centres, 
which in turn send an impulse to the iris. This being the case, 
the preservation of the skin pupillary reflex shows that the arc 
M D I E is functionally active. 

Movements of Accommodation. — Movements of the pupil 
with accommodation are brought about through the oculo-motor 
nerve, and are probably of the nature of habitual associated move- 
ments. They denote the integrity of the oculo-motor nerve and 
its nucleus. 

Argyll Robertson Pupil. — In the Argyll Robertson pupil 
the failure of the pupil to contract under the stimulus of light 
shows that there is a lesion in the arc E C B F, or, in other words, 
that either the optic nerve or its centre, or the connection between 
the optic centre and the oculo-motor centre, or the oculo-motor 
centre or its nerve, is diseased. The retention of normal vision 
shows that the optic nerve and its nucleus are perfect. The occur- 
rence of movements during the process of accommodation proves 
that the oculo-motor nerve and its centre are active: the interrup- 
tion in the arc E C B F must therefore be between the optic and 



340 DIAGNOSTIC NEUROLOGY. 

the oculo-motor centre^ or, in other words, in the commissural 
fibres which connect the optic and the oculo-motor centre. The loss 
of the skin pupillary reflex proves that there is some interruption 
in the arc M D L, — this interruption probably being in the spinal 
cord and due to the lesion which interrupts the continuity of the 
pathway between the oculo-motor and the optic centre. 

Diseases in which the Pupils are deranged. — There are certain 
centric nervous diseases of which the pupillary symptoms require 
more detailed discussion than has yet been given them. Prominent 
among these affections is locomotor ataxia^ in which the pupils 
may be altered during the earliest stages. They may be either 
dilated or abnormally contracted. They may be equally af- 
fected, or one may be contracted and the other dilated, or one 
may be dilated and the other normal. According to Eulenburg, 
the simultaneous occurrence of myosis and mydriasis happens 
only in the late stages of the disorder. Myosis is much more 
frequent than mydriasis : thus, Eulenburg in sixty-four cases 
noted mydriasis in nine, myosis in twenty-eight. In the rare 
cases in which the cervical spinal cord is first attacked, myosis 
occurs very early. The degree of contraction varies greatly in 
different cases, but is often excessive: it is usually greater on 
one side, and often varies from time to time in the same case. 
T. Grainger Stewart states that he has seen the myosis increase 
during a gastric crisis, whilst Charcot affirms that during the 
pain of a crisis the pupil sometimes dilates. 

In multiple cerebral spinal sclerosis the pupil is variously 
affected. With or without ptosis there may be dilatation of the 
pupil, or myosis may exist; in some cases there is inequality of 
the pupils. It is affirmed by Parinaud [Progrh Medical^ vol. xii. 
p. 642) that there is a stage of the disorder in which the pupil- 
lary reflexes are exaggerated, and that if at the same time one 
eye is affected more than the other, monocular myosis may be 
produced whenever the patient goes into the light. According 
to the same author, whenever myosis exists in a person presenting 
symptoms of central nervous disease, if the pupil still reacts to 
light the cause is probably multiple sclerosis, and not locomotor 
ataxia. 

The Argyll Robertson pupil is probably pathognomonic of 
degeneration of the upper spinal cord, including in this term the 



DISTURBANCES OF THE SPECIAL SENSES. 341 

medulla. It has been especially noted in locomotor ataxia^ of 
which disease it is very characteristic. It also occurs in pro- 
gressive paralysis of the insane. As, however, descending spinal 
degenerations are very common in general paralysis, the Argyll 
Robertson pupil is probably produced by these secondary spinal 
lesions, and not by the aflPection of the brain-cortex. 

In general paralysis of the insane, the pupils may be equal 
and normal ; or equal and contracted ; or equal and dilated ; 
or unequal on account of one being contracted and the other di- 
lated, or on account of one being normal and the other dilated 
or contracted. Of all these phenomena, inequality of the pupils 
is most frequent and most characteristic. It may vary from day 
to day. One day the pupils may be equal, the next day they may 
be unequal ; or to-day the pupils may be unequal because the right 
is contracted, and to-morrow they may be unequal because the 
right is dilated. This shifting inequality of the pupils is especially 
characteristic of the disease, and may be a prodromic symptom. 

Dr. E. Mendel {Paralyse der Irren, Berlin, 1880, p. 147) 
states that he has seen inequality of the pupils as long as three 
and a half years before the outbreak of mental disturbance, whilst 
Foerster (quoted by Norris) relates the case of a colleague who, 
while yet of sound mind, jokingly said that on account of his 
pupils having become unequal he thought of taking quarters in 
an insane asylum, and who actually died a few years later in 
such an institution. Along with the dilatation of the pupil the 
shape [of the eyeball may be affected. Mobeche and Mendel 
noted an increased convexity of the ball and a narrowing of the 
opening of the eye. The whole eye may also appear to be smaller 
than normal, on account of the paralysis of Mueller's muscles 
or of spasm of the orbicular muscle. In some cases ptosis or 
strabismus and double vision occur. After the epileptic attack 
of advanced progressive paralysis conjugated deviation of the eyes 
(Prevost's symptom, so called) is occasionally present. 

DISTURBANCES OF VISION. 

Method of Testing Vision. 

In order to determine the acuteness of sight, test-types are 
employed, in which the letters are of various sizes, and numbered 



342 DIAGNOSTIC NEUROLOGY. 

according to the distance at which each size subtends a visual 
angle of five minutes, and the strokes of the letters an angle of 
one minute. This is considered to be a standard for average 
normal vision. The types constructed by Snellen, made upon this 
plan, are in common use, although many other series of test-types, 
equally useful, especially those in which the necessary alterations 
have been made to render them conformable to the metric system 
of measurement, are employed. When it is desired to test the 
acuity of vision, the patient should be placed twenty feet from the 
type-card, in a well-lighted room, and each eye tried separately. 
If the letters of No. XX are read, vision is normal, or 1, but 
if, standing at the same distance, no smaller letters than those 
numbered XL can be discerned, vision is ^. It is usual to ex- 
press these results according to the formula V = :^, in which V 

stands for visual acuteness, d for the distance of the patient from 
the card, and D for the number of the type : so that in these in- 

20 20 

stances the vision would be recorded ,^ and ^ • Twenty feet 

has been found to be a useful distance : any other may be chosen, 
provided it does not place the patient closer to the test-card than 
ten or twelve feet. 

It often becomes a matter of importance to test the field 
of vision, or that space throughout which the eye is able to see 
while it remains stationary at a given distance from a fixed point. 
This may be roughly done by following the appended directions. 
Place the patient with his back to t>e source of light, and have 
him fix the eye under observation, the other being covered, upon 
the centre of your face, at a distance of two feet. Then move 
your fingers in various directions midway between yourself and 
him on a plane with your own face until you determine the 
limits of his indirect vision, controlling at the same time the 
extent and direction of your movements by your own field of 
vision. This plan of examination may be improved by placing 
small square pieces of white or colored paper on the end of a rod, 
and proceeding with the examination as before. 

Although the field forms part of a hemisphere, it may be 
projected upon a flat surface and a useful map of the visual field 
obtained. Thus, let the patient be placed twenty-five centimetres 



DISTURBANCES OF THE SPECIAL SENSES. 



343 



from a blackboard, which may be conveniently ruled in squares, 
and fix the eye under observation upon a small white mark. Then 
move the test-object, either a piece of white chalk* fastened in 
a black handle, or, better, pieces of white and colored paper one 
centimetre square, from the periphery towards fixation, until the 
object is seen or the color named ; then mark this position. If 
eight peripheral points be marked and afterwards joined by a line, 
a fair map of the field of vision will be obtained, and may be 
transcribed upon a chart ruled for the purpose. This method is 
not entirely accurate if the field is larger than 45°, because beyond 
that angle, on flat surfaces, the object is too far away from the eye 
to make the examination exact. 











ElG. 


22 








































r 




















































































r" 


• — ■' 






-A 


\ 
















/ 


,-' 








\ 


\ 




\ 










( 




* 








■•.. 




\ 






\ 




\ 


i. 






/ 




/ 




1 






\ 




I 


s 




— ^ 




, 




/ 


' 


J 






V 




'•■•v. 


--V 


! 




,.yl 
















N 














J 














V 


N , 






-^ 




































Fig. 22 represents the noi.jial field of vision of the right eye 
taken on a flat surface : the outer marking is the boundary for 
white, and the others respectively for blue and red. For accurate 
measurements of the field, and for any measurements beyond 45°, 
an instrument known as a perimeter must be employed. This con- 
sists essentially of an arc marked in degrees, which rotates around 
a central pivot that is at the same time the fixing-point for the 
patient^s eye. The test-object, square pieces of white, and colored 
paper affixed upon a piece of dead-black cardboard, is moved 
from without inward, and the point in each meridian, where it is 
recognized, noted. The result is transcribed upon a chart prepared 



^ In amblyopic eyes the field may be taken in a dark room and a candle be 
substituted for the piece of chalk. In this way, so long as the patient can see 
at all, the field* may be mapped. 



344 DIAGNOSTIC NEUROLOGY. 

by having ruled upon it radial lines to correspond to the various 
positions of the are, and concentric circles to denote the degrees. 

Fig. 23 represents the field as taken with the perimeter. The 
fields for color are smaller than the field for white, and are green, 
red, yellow, and blue from within outward. Landolt's investiga- 
tions — those usually quoted — make the normal fields for color as 
follows : 

Blue. Red. Green. 

Upper 60° 35° 30° 

Outer 80° 70° 55° 

Lower 55° 45° 35° 

Inner 50° 40° 30° 

As many meridians may be tested as are needful : four are 
usually sufficient. 

Disorders of Sight 

The disorders of vision which require study by the neurologist 
are — amaurosis, or nerve-blindness, including amblyopia, or im- 
paired vision ; hemianopsia, or loss of vision over one-half (lateral 
or vertical) of the eye; scotomata, or patches of blindness; and 
contraction of the field. 

Anatomy of Optic Tract. — Before discussing these various visual 
disturbances it is perhaps well to summarize briefly the anatomy 
of the optic tract. The band of white fibres known as the optic 
tract arises from the posterior part of the thalamus, the geniculate 
bodies, and the superior quadrigeminal bodies. From the under 
part of the thalamus it suddenly bends forward, and as a flattened 
band passes obliquely inward across the upper anterior surface of 
the cerebral peduncle, to which it is closely attached ; after this it 
adheres to the tuber cinereum, from which and from the lamina 
cinerea it is said to receive fibres. In this way it reaches the optic 
chiasm, an oblong flattened body situated upon the olivary emi- 
nence of the sphenoid bone. In the chiasm the fibres of the 
nerves coming from the tract divide : the larger or outer band de- 
cussates with its fellow, or, in other words, crosses over to enter the 
optic nerve as it emerges from the opposite side of the chiasm and 
to be finally distributed to the nasal half of the retina. The inner 
or smaller band of fibres passes on through to the chiasm, without 
decussation, to the outer side of the retina of its own eye. These 
fibres are the only ones that have direct relations with vision, — 



DISTURBANCES OF THE SPECIAL SENSES. 345 

the inferior comriiissure of Gudden (the posterior loop of Hannover) 
being composed of fibres which pass through the optic tracts and 
the posterior portion of the chiasm to connect the two inner genic- 
ulate bodies, whilst the existence of the inter-retinal fascicule, 
which Hannover believed to pass through the anterior edge of the 
chiasm and to be a retinal commissure, is denied by most recent 
anatomists. Although the optic tracts are closely connected with 
the corpora geniculata and the anterior corpora quadrigemina, 
it seems clearly made out that these centres have not the function 
of vision. The conscious perception of retinal images takes place 
in the brain-cortex. The exact position at which it occurs has 
been much discussed, but the consideration of this is so closely 
bound up with the question of hemianopsia that it is better post- 
poned for the present. 

Amaurosis. — Amaurosis was the term employed by the old 
surgeons to designate cases in which they could find no cause 
in the eye for the loss of sight. In recent times it has come to 
signify blindness from disease of the nerve or of the nerve-centres. 
Amblyopia is a partial loss of vision of nervous origin. The two 
terms are sometimes rendered synonymous by means of adjectives: 
thus, partial amaurosis is used to signify amblyopia, and complete 
amblyopia is sometimes employed instead of amaurosis. There 
is at present sufficient clinical evidence to show that a temporary 
amaurosis may be produced by a distant irritation. The researches 
of Dr. Brown-S6quard {London Lancet, July^ 1861) proved, many 
years ago, that amaurosis may occur in diseases of the cerebellum 
without alteration of the nerve. Dr. Davaine is said to have 
reported twelve cases of amaurosis produced by intestinal worms. 
Dr. Brown-S6quard has seen it in animals following injury to the 
spinal cord, and has noticed its occurrence in man as the result of 
irritation of the nerves of the stomach. 

Amaurosis may also be an hysterical symptom. Under these 
circumstances, its true nature is usually revealed by the sudden- 
ness with which it develops and disappears, as well as by the co- 
existence of other pronounced hysterical symptoms. (See, also, 
page 259.) 

Organic Amblyopia. — Partial or complete neurotic blindness 
may be due to lesions of the peripheral visual nervous system or 
to centric diseases. For reasons that will become manifest during 



346 DIAGNOSTIC NEUKOLOGY. 

the study of hemianopsia, a lesion of the brain which directly 
causes loss of vision by acting on the visual centres almost in- 
variably affects only a portion of the field in both eyes, causing 
hemianopsia. A central lesion which produces general ambly- 
opia, affecting the whole field of each eye, must be double and im- 
plicate both cerebral hemispheres. Such a lesion is so excessively 
rare that it may be laid down as a diagnostic rule that an organic 
amblyopia is due to peripheral disease. Such disease may be a 
gummatous, gliomatous, or sarcomatous tumor so situated as to 
press upon the optic chiasm or the optic tract at the base of the 
brain. It may be an inflammation of the optic nerve, either a 
true neuritis or a choked disk. Almost invariably inflammations 
of the optic nerve are symmetrical and affect alike both eyes. 

Toxccmic Amblyopia, — Toxa3mic amblyopia is usually of organic 
origin, but, as the lesion is directly produced by the poisoning, and 
is likely to be recovered from on removal of the poison from the 
system, the separation of toxsemic amblyopias is of practical im- 
portance. The most common and the most important of the class 
is the loss of vision produced by tobacco. In a large proportion 
of cases the excess in the use of tobacco has been associated with 
an excess in the use of alcohol, and there has been much discus- 
sion as to which of these agents was the cause of the optic de- 
rangement. The amblyopia is frequently present in those who 
smoke excessively but do not drink, and tobacco seems to exert 
the more potent influence. The victim of tobacco amblyopia 
shows no difficulty or awkwardness in going about, but especially 
complains that vision is very bad in direct sunlight. He almost 
invariably sees better on dull days, and in the early morning and 
evening. If this be not noted by the patient himself, it may be 
shown by testing vision with type in full daylight and again in 
a darkened room. An examination of the visual field will show 
that a great functional defect is in the centre of the field, occupy- 
ing an oblong or oval patch which extends from the fixing-point 
(corresponding to the macula lutea) out towards and often imme- 
diately beyond the blind spot (corresponding to the disk). This 
central scotoma is relative, and not absolute; i,e., loss of vision 
in it is never complete. It is especially marked for the perception 
of colors, for green and red in particular: the former is usually 
described by the patient as ^^ white" or "gray," and the latter as 



DISTURBANCES OF THE SPECIAL SENSES. 347 

^M^rown^^ or "no color at all/^ In most cases the scotoma is 
smaller than the visual field for central colors, green and red, and 
hence a zone is present beyond the scotoma in which these colors 
are observed. This is especially the reason that the patient will 
recognize the color of a large body and mistake that of a very 
small one. 

The scotoma of tobacco amblyopia is invariably anatomically 
symmetrical, occupying exactly the same position in each retina. 
It is believed by oculists to be chiefly due to the change in the 
peripheral portion of the nerve-axis. It has been asserted in 
the rare cases in which the scotoma is central and surrounds the 
fixation-spot equally on all sides that the cause is alcohol. Dr. 
Edward Nettleship {St Thomases Hospital Reports, vol. ix.) 
states, however, that in all the cases of such scotoma which he has 
i seen the patients w^ere smokers. And Dr. G. De Schw^einitz has 
] reported {Philadelphia Medical Times, 1886) an example of such 
scotoma in a woman who used neither alcohol nor tobacco, but 
made cigars, and in whom the eyes became normal after she left 
her occupation. In investigating a case it should be remembered 
i that chewing tobacco is more injurious than smoking. 
, Cases of blindness directly produced by lead are stated to 
occur. Such cases, however, must be very infrequent, since I 
ihave seen a great many cases of lead-poisoning, but never 
jSuch a one. More frequent is the indirect production of blind- 
ness by lead. Thus, the saturnine Bright^s disease may cause a 
ursemic degeneration of the retina, and in cases of violent satur- 
nine brain-disease {encephalopathia saturnina) choked disk is 
usually present, with consequent loss of vision. According to 
Xorris {System of Practical Medicine, Philadelphia, 1886, vol. 
iv. p. 804), "excessive overdoses of quinine impair the sight, 
and in some cases have produced temporary but absolute blind- 
ness. The usual symptoms are a deterioration of the central 
vision, with contraction of the field. The ophthalmoscopic ex- 
amination reveals a pallid disk, with marked diminution in the 
size of the retinal arteries and veins.'^ Many years ago I saw a 
complete blindness, lasting eight or ten hours, produced in a 
young lady by fifteen grains of sulphate of quinine : that the alka- 
loid was the cause of the symptoms was proved by their recur- 
rence on a repetition of the dose. Santonin in toxic doses pro- 

I 



348 DIAGNOSTIC NEUROLOGY. 

duces dilatation of the pupil and great disturbance of vision. 
(See author's treatise on Therapeutics; also Virchow^s Archiv^ 
Bd. XX., 1860; Bd. xxviii., 1863.) The action of salicylate of 
sodium so closely resembles that of quinine that it is probable 
amblyopia might be caused by it ; and Gatti (quoted by Norris) 
reports a case of transient amblyopia attributed to the ingestion 
of one hundred and twenty grains of salicylate of sodium. 

Heniianopsia. — Hemianopsia is a loss of vision in one-half of 
the eye. Since the rays of light cross in the eye, the part of the 
retina which is blind is always opposite to the object which cannot 
be seen. Thus, when the eye sees no objects to the left of it, the 
symptom is termed left hemianopsia, although the blind spot is 
on the right side of the retina : in other words, when an object 
in front of the line of the nose is not seen, the hemianopsia is 
spoken of as nasal, although the temporal half of the retina is 
paralyzed. 

Hemianopsias are best divided for our purposes into horizontal, 
in which the dividing line between the paralyzed and the active 
portion of the retina is horizontal, and vertical, in which the 
dividing line is vertical.* 

Horizontal hemianopsia may be inferior or superior. It is al- 
most always due to disease of the eye. The only known nerve- 
lesion capable of producing it is a tumor or other alteration of 
the hemisphere so situated and developed as to press downward 
upon one optic tract. Such cases have been recorded. 

Vertical hemianopsia is almost invariably due to nerve-lesion. 
A large number of terms have been employed to designate the 
varieties of vertical hemianopsia. Of these the following seem 
worthy of adoption : 

a. Temporal hemianopsia, in which both temporal fields are 
involved. 

b. Nasal hemianopsia, in which both nasal fields are involved. 

c. Lateral or homonymous hemianopsia, in which corresponding 

^ The term hemiopia has been used by some writers as synonymous with 
hemianopsia ; but Dr. Seguin defines it, *' as now accepted," to signify loss of 
perceptive power in one-half of the retina, whilst hemianopsia means obscura- 
tion of one-half of the visual field. A right hemiopia is equivalent, there- 
fore, to a left hemianopsia. To avoid confusion, I shall not use the term 
hemiopia. 



DISTURBANCES OF THE SPECIAL SENSES. 



349 



fields of the eyes are involved : thus, both left or both right fields 
are destroyed. 

EiG. 24. 





Diagram of the fields of vision in a case of temporal hemianopsia. The shadinij 
represents the areas of absent vision ; the outer boundary of the shading is the limit of 
the normal field. The patient was aged 40, had brain-syphilis, and probably a deposit 
upon the chiasm. V = 3^. Both optic nerves gray-green in color and atrophic. 

Both temporal and nasal hemianopsia are exclusively caused, so 
far as our present knowledge goes, by lesion of the optic chiasm. 



Fig. 25. 





Diagram of the fields of vision in a case of left lateral hemianopsia. The outer 
boundary of the shading is the limit of the normal field ; the shading represents where 
vision was lost. The left half of each field is absent, and the right halves are con- 
tracted. The patient was a woman, aged 45. V = 34- Optic nerves oval, gray in 
their deeper layers, but superficially capillary. Central circulation unchanged. Seven 
months before examination the patient had a temporary left-sided hemiplegia. 

Lateral hemianopsia appears to be always produced by lesions 
of one optic tract, or of the more central parts of the optic appa- 
ratus as far posterior as the cortical centre for vision in one hemi- 
sphere. Central lesions causing lateral hemianopsia are usually 
embolic or hemorrhagic, and hence are apt to be suddenly de- 
veloped. Lesions of the optic tract causing lateral hemianopsia 



350 DIAGNOSTIC NEUROLOGY. 

are probably always slowly progressive, being of the nature of 
the growths or exudations. 

A study of the diagram on the opposite page, after Prof. Seguin, 
will show the correctness of the following deductions : 

1. When a lesion involves one optic tract it causes lateral 
hemianopsia, the side of the hemianopsia being opposite to the 
side of lesion. Thus, if the right tract is pressed upon, a left 
lateral hemianopsia results. 

2. A lesion acting upon one side of an optic tract so as to com- 
press only some of its fibres might produce one-sided hemianopsia, 
either nasal or temporal, according to the fibres involved. If the 
pressure be upon the outer side, the hemianopsia will be nasal; 
if it be on the under side, the hemianopsia will be temporal. 
Thus, tumor T 1, in the diagram, acting only feebly, would cause 
a unilateral nasal hemianopsia; T 2, a unilateral temporal hemi- 
anopsia; although either tumor, if sufficiently large to compress 
the whole tract, would cause an homonymous right hemian- 
opsia. 

3. When both sides of the optic chiasm are pressed upon by a 
lesion not sufficiently powerful to obliterate the function of the 
chiasm, both lateral fasciculi are pressed upon, and a double nasal 
hemianopsia results. Thus, the tumors T 3 and T 4 acting 
together would cause a double nasal hemianopsia. 

4. When the lesion involves the frontal and posterior borders 
of the chiasm it injures the decussating nerve-fibres, and thereby 
causes double temporal hemianopsia. Thus, the tumors T 5 and 
T 6 acting together would cause a double temporal hemianopsia. 

These forms of hemianopsia are almost invariably accompanied 
by changes in the optic disk and other evidence of pressure or 
change in the basal nerves, which symptoms are very apt to be 
wanting in lesions that involve the cortical centre. 

The most elaborate study which has been made of lateral, cor- 
tical hemianopsia is that of Prof. E. C. Seguin {Journal of Nervous 
and Mental Diseases, vol. xiii.). In this paper sixteen cases are 
analyzed, leading, as Dr. Seguin believes, to a final determination 
of the position of the cortical centres which are connected with 
vision. These cases show^ — 

" That lesions of the corpus geniculatum laterale, pulvinar, and 
latero-caudad, etc., of the thalamus may cause hemianopsia, — 



DISTURBANCES OF THE SPECIAL SENSES. 



351 



usually in association with hemiansesthesia and hemiplegia, or 
with hemiansesthesia alone. 



Fig. 26. 



_ L^ r,K _ 



R. }J, P 




L.O.S /..O.O 

Diagram of Yisual Paths ; designed to illustrate specially Left Lateral Hemianopsia 
from any lesion. L. T. F., left temporal half-field. R. N. F., right nasal half-field. 
0. S., oculus sin. 0. D., oculus dexter. N. T., nasal and temporal halves of retinae. 
N. 0. S., nervus opticus sin. N. 0. D., nervus opticus dext. F. C. S., fasciculus cru- 
ciatus sin. F. L. D., fasciculus lateralis dext. C, chiasma, or decussation of fasciculi 
cniciati. T. 0. D., tractus opticus dext. C. G. L., corpus geniculatum laterale. L. 0., 
lobi optici (corpus quad.). P. 0. C, primary optic centres, including lobus opticus, 
Corp. genie, lat., and pulvinar of one side. F. 0., fasciculus opticus (Gratiolet) in the 
internal capsule. C. P., cornu posterior. G. A., region of gyrus angularis. L. 0. S., 
lobus occip. sin. L. 0. D., lobus occip. dext. Cu., cuneus and subjacent gyri con- 
stituting the cortical visual centre in man. Tlie heavy or shaded lines represent parts 
connected with the right halves of both retinse. 



"That a lesion of the white substance of the occipital lobe 
in the caudal radiations of the internal capsule may cause hemi- 
anopsia, alone or with hemiansesthesia. 

" That lesions of the supra-marginal gyrus, angular gyrus, and 
inferior parietal lobule with the subjacent white substance may 



352 DIAGNOSTIC NEUROLOGY. 

cause hemianopsia, with or without other symptoms (hemiplegia 
loss of muscular sense, word-deafness, etc.). 

" That a lesion of greater extent, involving the speech-centre, 
the motor convolutions, and the parts enumerated above (4), due 
usually to embolism or thrombosis of the entire Sylvian artery, 
will, when existing on the left side, produce aphasia, alexia, hemi- 
anopsia, and hemiplegia. 

" That lesions of the occipital lobe, cortex, and subjacent white 
matter produce blindness when bilateral, and hemianopsia when 
unilateral. This conclusion is in accord with Exner's (1881)." 

It will be remembered that there are two distinct views held by 
physiologists, Munk teaching that the centres for conscious visual 
perception are in the occipital lobe, and Ferrier that they are in 
the angular gyrus. The elaborate discussion of the physiological 
evidences is out of the province of the present article, but the 
explanation of these apparently discordant results as given by 
Dr. E. C. Seguin is probably correct, — namely, that the white 
band of conducting fibres known as the optic fasciculus of Gra- 
tiolet and Wernicke, whilst passing from the posterior part of 
the thalamus to the cuneus of the occipital lobe, lies so close to 
the inferior parietal lobule and the angular gyrus that a lesion of 
the angular gyrus or of the supra-marginal gyrus, or even of the 
inferior parietal lobule, might press upon or otherwise involve this 
conducting fasciculus, and thus interrupt the communication be- 
tween the perceptive visual centres and the eyes. Both Ferrier 
and Munk may, therefore, be correct in their views, — the loss of 
sight in Ferrier^s experiments being due not to the wounding of 
the angular gyrus itself, but to the interference with the band 
conducting the white matter beneath the gyrus. 

The following rules for the diagnosis of the seat of the lesion 
in cases of hemianopsia are those of Dr. Seguin, and seem to me 
correct : 

"1. Lateral hemianopsia always indicates an intra-cranial lesion 
on the opposite side from the dark fields. 

" 2. Lateral hemianopsia, with pupillary immobility, optic neu- 
ritis, or atrophy, especially if joined with symptoms of basal dis- 
ease, is due to lesion of one optic tract, or of the primary optic 
centres on one side. 

'^ This diagnosis may be further strengthened and rendered quite 



DISTURBANCES OF THE SPECIAL SENSES. 353 

certain by seeking for and finding one-sided pupillary reaction, 
as recently suggested by Wernicke. He ingeniously predicts that 
only one lateral half of each iris will be found to contract by the 
reflex effect of light when one optic tract has been interrupted. 
He designates this as ' hemiopic pupillary reaction.^ 

'' 3. Lateral hemianopsia/ or sector-like defects of the same geo- 
metric order, with hemianaesthesia and choreiform or ataxic move- 
ment of one-half of the body without marked hemiplegia, is 
probably due to lesion of the caudo-lateral [posterior lateral] part 
of the thalamus, or of the caudal division of the internal cap- 
sule. 

^'4. Lateral hemianopsia, with complete hemiplegia (spastic 
after a few weeks) and hemianaesthesia, is probably caused by an 
extensive lesion of the internal capsule in its knee and caudal 
[posterior] part. 

" 5. Lateral hemianopsia, with typical hemiplegia (spastic after 
a few weeks), aphasia if the right side be paralyzed, and with 
little or no anaesthesia, is quite certainly due to an extensive 
superficial lesion in the area supplied by the middle cerebral 
artery : we would expect to find (as in Case 26 by Westphal) soften- 
ing of the motor zone and of the gyri lying at the extremity of 
the fissure of Sylvius, — viz., the inferior parietal lobule, the supra- 
marginal gyrus, and the gyrus angularis. Embolism or throm- 
bosis of the Sylvian artery would be the most likely pathological 
cause of the softening. 

" 6. Lateral hemianopsia, with moderate loss of power in one- 
half of the body, especially if associated with impairment of 
muscular sense, would probably be due to a lesion of the inferior 
parietal lobule and gyrus angularis, with their subjacent white 
substance penetrating deeply enough to the visual centre. 

'^ 7. Lateral hemianopsia, without motor or common sensory 
symptoms, this symptom alone, is due, I believe, from the con- 
vincing evidence afforded by Cases 28, 29, 41, and 45, to lesions 
of the cuneus only, or of it and the gray matter immediately sur- 
rounding it on the mesal surface of the occipital lobe in the hemi- 
sphere opposite to the dark half-fields. Most surgical cases come 
at once, or after convalescence, within this rule, or in No. 6 
(Case 3V^ 

Contraction of the Field of Vision. — Contraction of the 

23 



354 



DIAGNOSTIC NEUROLOGY. 



field of vision occurs in several forms of sclerosis of the nervous 
system, and is probably the result of secondary organic changes 
in the optic nerve. It is especially frequent in locomotor ataxia, 
but may occur in multiple sclerosis. The contraction is concen- 
tric, and, according to Forster, in a majority of cases is generally 
more marked on the outer side. The curve that bounds the field 
of vision is usually irregular with emarginations, which have a 
tendency to take the form of sectors w^hose centre is the optic 
papilla. The contraction of the field progresses steadily and with 
greater rapidity than the loss of sight, so tliat vision may be sat- 
isfactory although the sensitive portion of the retina is almost 
limited to the macula. Microscopic studies of the optic nerve 
have shown that the contraction of the field is connected with a 
desreneration of the nerve-fibres w^hich commences in the outer 
portions of the optic nerve and travels towards its centre. Dis- 
order of the color-sense usually accompanies the contraction of 
the field. The power of perceiving yellow and blue is preserved 
for a long time, whilst blindness for green and red is early de- 
veloped. According to M. Abadie, it is possible to distinguish 
between parenchymatous and interstitial atrophy of the optic 

Fig. 27. 







/- ^ 


/TI„-^ X 


T^Sm ) r 


1 ytL_. / 


y 


il^ 





Diagram of the fields of vision for white and red and central scotomata, embracing 
fixation and the blind spot, from a case of locomotor ataxia. Patient aged 58; Y=^g. 
Both optic nerves showed gray atrophy. Inasmuch as he smoked two ounces of to- 
bacco a week, and drank " a few" glasses of whiskey daily, the influence of these in 
producing the scotomata cannot be entirely excluded. For a similar case see Gowere, 
Medical Ophthalmoscopy, p. Ill, Fig. 20. 



nerve by a study of the relation between the general sight and 
the color-sense. When the loss of vision is still greater than 
^, if green is no longer perceived, and red and yellow are recog- 
nized with difficulty, there is parenchymatous atrophy; if, on 
the other hand, with an acuteness of vision inferior to -^^ the 



DrSTURBAXCES OF THE SPECIAL SEXSES. 355 

perception of color is satisfactorily maintained, there is probably 
interstitial atrophy. 

Multiple sclerosis may produce disturbances of vision similar to 
those caused by locomotor ataxia. Out of fifty cases observed by 
Dr. R. Gnauck {Neurolog, Centralblatt, 1884, iii. 315), vision was 
affected in twenty-two. In some cases the disturbance of vision is 
monocular, probably as the result of the development of a focus 
of sclerosis in the nerve itself. According to Parinaud (Progres 
MMical, xii. 642), the amblyopia of multiple sclerosis, unlike 
that of posterior sclerosis, very rarely ends in total blindness ; but 
in two of Gnauck^s cases the loss of sight was complete. 

SENSE OF TASTE. 

The function of taste is shared by two nerves, — the glosso- 
pharyngeal and the lingual branch of the fifth, — the first supply- 
ing the posterior half or two-thirds of the tongue, the last the 
anterior half or third of the organ. Owing to this double nerve- 
supply, it is necessary, in testing the condition of the taste-sense, 
that the tongue be protruded from the mouth and be kept quiet 
after contact with the sapid substance until time has elapsed for 
the penetration of the latter. The gustatory filaments of the lin- 
gual branch of the fifth leave the nerve with the chorda tympani 
and pass to the facial nerve. Paralysis of the lingual branch of 
the fifth nerve after it receives the chorda tympani is therefore 
followed by loss of taste in the anterior part of the tongue ; as is 
also a lesion of the trunk of the facial nerve between the genicu- 
late ganglion and the point at which the chorda tympani separates 
from the facial nerve. There have been cases of paralysis of the 
facial nerve above the geniculate ganglion in which there has been 
no interference with the sense of taste, and, on the other hand, 
cases have been reported in which compression of the trigeminus 
nerve above the position at which the petrosal nerves join it has 
been followed by loss of taste. It is therefore probable that the 
gustatory fibres of the lingual nerve return through the petrosal 
nerves to the trunk of the trigeminus. There are, however, cases 
on record in which the taste-symptoms are very difficult of ex- 
planation, and it is possible that the course of the filaments varies. 

The glosso-pharyngeal nerve arises from the nucleus in the 



356 DIAGNOSTIC NEUROLOGY. 

medulla close to the nucleus of the vagus. The trunk emerges 
in the groove between the olivary body, and escapes from the 
skull through the jugular foramen. 

Hyperaesthesia of the sense of taste is sometimes seen in hys- 
teria. Hallucinations occur in insanity, and with extreme rarity 
are produced by organic disease of the nervous apparatus involved. 
They are very frequently present as the result of disorders of the 
intestinal tract : whether under these circumstances they should 
be looked upon as reflex or as the development of abnormal 
mouth-secretions is doubtful. 



SENSE OF SMELL. 

It is necessary in testing the sense of smell that such odorous 
substances be selected as are not irritant to the mucous membrane 
of the nose, lest the subject should detect their presence by their 
effect upon the branches of the trigeminal nerve in the nasal mu- 
cous membrane. Hyperaesthesia of the sense of smell is sometimes 
seen in hysteria, and theoretically should occur in inflammatory 
conditions of the olfactory tract, but I have never known of such 
a case. Hallucinations of the sense are sometimes seen in in- 
sanity, and also occur in diseases of the olfactory tract, when they 
are apt to usher in an epileptic convulsion. I have seen such 
symptoms produced by a gliomatous tumor involving the olfactory 
lobes. Loss of smell usually depends upon disease of the mucous 
membrane of the nose, but it may be caused by an affection of 
the olfactory lobes, and is occasionally seen in organic hemianses- 
thesia produced by a lesion involving the internal capsule. 



CHAPTER IX. 

DISORDERS OF MEMORY AND CONSCIOUSNESS. 

All functional acts are accompanied by, or dependent upon, a 
nutritive disturbance. It matters not whether the functional act 
is connected with thought, consciousness, or secretion, the genera- 
tion of nerve-force by the ganglionic cell and its transmission by 
nerve-fibre are accompanied by nutritive changes in these bodies. 
A nutritive act, although temporary, has a distinct tendency 
to impress permanently the part implicated ; and this tendency 
is especially pronounced in nervous tissue. All nervous tissue is, 
therefore, liable to be permanently affected by its own functional 
actions. This, it must be remembered, applies equally to normal 
and to pathological activities. Thus, the child in learning to walk 
by repeated efforts trains the lower nerve-centres until, in response 
to appropriate stimuli, a definite series of nervous discharges and 
transmissions occur independently of the will, and walking be- 
comes automatic. This, in short, is the history of all training, 
mental and physical. All nervous tissues, therefore, have memory, 
— i.e., the faculty of being permanently impressed by temporarily 
acting stimuli, the thing remembered being, in fact, the functional 
excitement. 

The recognition of the universality of memory in nerve-tissues 
is of great importance in the consideration and treatment of dis- 
ease. Thus, an epileptic fit is produced by a peripheral irritation. 
If that peripheral irritation be at once removed, the fit does not 
recur, and the patient is cured. If, however, the irritation be not 
soon taken away, but produce a series of convulsions, the fits 
may continue after the removal of the irritation, simply because 
of the permanent impress which has been made upon those cells 
in the brain-cortex whose discharge of nerve-force is the imme- 
diate cause of the epileptic paroxysm. The nutrition of the cells 
has been so altered that at irregular intervals they fill up and 
discharge nerve-force. 

Owing to this power of memory, a physical habit may become 

357 



358 DIAGNOSTIC NEUROLOGY. 

SO permanently engrafted upon the nervous system that the patient 
is unable to control it. An example of this is seen in the so- 
called habit-choreas : movements at first controllable, mere bad 
habits, become at last fixed, not to be altered by any power. 
The hysterical woman who gives way to hysterical nervous im- 
pulses thereby strengthens their hold upon the system, so that in 
time she may lose all power of control over the lower nerve- 
centres. Moral habits are formed in obedience to the same law. 
Self-control, enforced at first by discipline, may become at last in 
the child an integral function of the nervous centre, by a method 
parallel to that by which an accidental epilepsy is converted into 
a permanent disease. In the prognosis and treatment of disease, 
as well as in the training of the young, the full recognition of the 
power of habit — i.e., of unconscious memory — is a matter of vital 
importance. 

What is true of the lower nerve-centres and fibres is true of 
the upper ones. Intellectual acts or thoughts and perceptions 
tend to stamp themselves upon the centres connected with them, 
and when the function of the nerve-cell is connected with con- 
sciousness the changes which occur in the nutrition give origin 
to conscious memory, — i.e., to memory in the usual sense of the 
term. 

The methods of ordinary mental action seem to indicate either 
that special ganglionic cells are set apart for special forms of 
memory, or else that the single ganglionic cell is capable of dis- 
tinct acts of memory. Thus, one individual will remember one 
class of facts with great ease, to the exclusion of other matters, 
whilst the second person may readily remember those affairs 
which the first naturally forgets. Disease sometimes dissects out, 
as it were, the different forms of memory, isolating one from the 
other. It is Avell known that in the loss of memory which ac- 
companies senile changes of the brain, or is a prominent symptom 
in the first stage of general paresis, the power of remembering 
recent events may be lost, although the recollection of affairs 
which happened in childhood days is far more vivid than in the 
normal condition of the individual. Under these circumstances 
it may be considered that the ganglionic cells have lost their 
capability of receiving impressions, but not of recognizing impres- 
sions which were made long before. The separation of different 



DISORDERS OF MEMORY AND CONSCIOUSNESS. 359 

forms of memory is^ however, distinct from this. Thus, in a 
case of dementia recently under my care memory for ordinary 
events was almost entirely lost, and yet a joke or a ludicrous story 
would be remembered in all its details without apparent effort. 
It is well established that one form of memory — namely, that 
connected with language — has in most individuals a definite brain- 
location ; and it may be that each variety of memory has its own 
territory. 

In considering the disorders of memory I shall discuss, first, 
disturbances of specialized forms of memory ; secondly, disturb- 
ances of the general function. This arrangement may appear to 
be a reversal of the natural order, but the peculiar relations of 
memory to consciousness, and the directness with which a dis- 
cussion of either of these functions leads to a consideration of 
the other functions, render the plan which I have selected the 
more convenient. Of the special forms of memory which pre- 
sumably exist, the only one whose symptomatology is suflSciently 
worked out to necessitate discussion here is that connected with 
language. 

WOKD-MEMOEY. 

The power of speech may be lost by an individual from para- 
lytic or other affections of the larynx preventing the formation 
of sound ; from paralysis of the tongue and lips causing inabil- 
ity to pronounce words or letters ; and, finally, from derangement 
of the mental functions immediately connected with word-thought. 
To the voicelessness of laryngeal disease the name of Aphonia 
may be applied ; to that which is the result of affections or paral- 
ysis of the tongue or mouth, Aphcemia; whilst for the mental 
difficulty may be reserved the term Aphasia. These terms have, 
however, been employed with various significations by various 
authors. Aphsemia has been used to signify aphasia, and the 
condition which I have called aphsemia is known by some writers 
as ataxic aphasia, — a term which is, however, used by other writers 
to denominate a peculiar variety of aphasia. With aphonia and 
aphsemia we have at present no concern. 

Aphasia. — In aphasia the power of verbal expression or of 
word -perception is affected, although the general intelligence of 
the patient may be intact. In the completest form of aphasia, 



360 DIAGNOSTIC NEUROLOGY. 

when the patient can neither understand spoken or written lan- 
guage^ nor express himself either in words or in writing, the intel- 
ligence is to be judged of by the acts of the patient : thus, such 
an aphasic will understand the use of the pen, and perhaps at- 
tempt, if he be not paralyzed, to write, or he will use properly 
a spoon or a knife, although he has no knowledge of the lan- 
guage or written symbols habitually employed to represent such 
articles. 

Aphasia is in many cases not complete, — that is, it does not 
affect all the mental functions connected with speech. In 1880, 
Dr. Magnan divided the cases of aphasia into two groups : first, 
those cases in which all connection between words and their 
meanings is lost, so that the aphasia is complete ; to these cases 
he gave the name of Verbal Amnesia: secondly, cases in which 
the subject is able to comprehend spoken language, but has lost 
the power of expressing himself; thus, when asked to pick up a 
pen from the table, the patient does so, but holding the pen is 
unable to name it: to this partial or incomplete aphasia Magnan 
gave the name of Logoplegia, 

As long ago, however, as 1843, Dr. Lordat, of Montpellier, 
reported cases of aphasia, and clearly recognized the existence of 
much more partial and distinct forms of the affection than those 
outlined by Magnan; and in 1874, Wernicke, under the name of 
Sensory Aphasia, described certain peculiar cases similar to those 
noted by Lordat. In 1874, Kussmaul also reported cases of 
sensory aphasia. Magnan and Kussmaul have disputed much 
concerning their rights to priority, but they each were long ante- 
dated by Dr. Lordat. 

Kussmaul {Ziemssen^s Oydopcedia, vol. xiv.), in an extraordina- 
rily elaborate and difficult-to-be-read article upon speech, divides 
aphasia as follows : 

First. Ataxic Aphasia, or that condition in which the patient 
has an entire loss of speech, although written and spoken lan- 
guage is understood. In pure ataxic aphasia there is no agraphia, 
or loss of the power of writing, so that the subject may be able 
to transact by writing the most complex business. When agra- 
phia is added to ataxic aphasia the patient is entirely unable to 
communicate with his fellows except by rude signs. Agraphia 
is not dependent upon any loss of control over the finer move- 



DISORDERS OF MEMORY AND CONSCIOUSNESS. 361 

meets of the hand. Thus, in a case reported by Spamer, a young 
woman completely agraphic was still a skilful seamstress. The 
facial expressions of emotion are usually preserved, so that anger, 
sorrow, etc., are expressed in the face, and sign-language — indeed, 
the whole mimetic faculty — may be normal. In very rare cases 
sign-speech is also lost, so that the patient is no longer able to 
communicate by pantomime. 

Second, Amnesic Aphasia, in which the idea is present but 
the word is wanting, although articulation is '^ at the service of 
the word.^^ Under these circumstances the patient is unable to 
talk, although he can still repeat and also write out words which 
are spoken to him. In partial amnesic aphasia proper names are 
the first to be lost, next names of things, and finally nouns in 
general. The patient will often paraphrase the noun which he 
cannot remember. Thus, a pair of scissors may be called " that 
with which one cuts f the window, " that through which one sees.^^ 
The early forgetfulness of proper names is evidently founded 
upon their isolated arbitrary character, which fails to link them 
with the world of word-thought, and renders them even in health 
apt to be forgotten. In some cases of amnesic aphasia it is only 
certain letters that are left out. Thus, L. Schlessinger details 
the case of a boy who invariably omitted the initial consonants, 
both in writing and in speaking. 

Third. Word-deafness and word-blindness, constituting the Sen- 
sory Aphasia of some authors. The subject of word-blindness is 
able to express his ideas in conversation with his normal fluency, 
and to understand all that is said to him, also to copy written 
language and with the pen to put down upon paper his ideas, yet 
he is unable to read printing or waiting. Thus, in a case reported 
by Charcot the patient suffering with partial right hemiplegia 
was unaware that he had any disorder of word-thought until he 
wished to give certain orders about his business affairs. These 
he wrote, and afterwards, in order to be sure of their correctness, 
undertook to read what he had written, when he found that he 
could not recognize a single word. 

In word-deafness, although the sense of hearing is intact, and 
although the individual is able not only to express himself in 
conversation, but also to write, to read, and to understand writing, 
he comprehends nothing that is said to him by word of mouth. 



362 DIAGNOSTIC NEUROLOGY. 

He hears distinctly, but cannot connect the sound of the word 
with the object which it symbolizes. 

Fourth. Paraphasia^ or that condition in which the person is 
unable to use words in their proper sense, speaking, it may be, 
with considerable fluency, but perpetually using one word for 
another. 

Fifth, Agrammatisma or Akataphasia, in which all the rules 
of grammar are lost, so that the parts of speech are hopelessly 
intermingled. 

It seems logical to consider the fourth and fifth varieties of 
aphasia of Kussmaul as simply partial aphasias, in which the 
relations of words with ideas have become dislocated but not 
completely disjoined. If all peculiar forms of partial aphasia must 
be defined and named, the list will have to be much extendal 
beyond that of Kussmaul. Thus, I might instance a case reported 
by Dr. Grashey {Sitzungsberichte Med. Gesell. Wurzhurg^ 1884, 
No. 9), in which the patient understood conversation, and read 
and wrote freely, but in attempting to talk was frequently un- 
able to remember words, except by writing and then reading 
them. It was his common practice to write WMth his forefinger 
upon the palm of his left hand each word, letter by letter, and then 
immediately pronounce it. I have heard or read of a case in 
which the patient repeated backward the sentence that he was 
trying to utter, beginning at the end of the sentence and at the 
end of each word. Instead of " John is a bad boy,'^ the patient 
would say, '^ Yob dab a si nhoj.'' 

As was pointed out by Dr. Hughlings-Jackson in 1864 {Lond. 
Hosp. Report, 1864), the faculty of intellectual speech may be 
lost whilst emotional speech remains to a greater or less extent. 
Thus, a person who has been considered completely aphasic, after 
obstinate silence to all questions and remarks, will, in a burst of 
anger, suddenly swear violently. Or, as in a case seen by Dr. 
Jackson, an aphasic who is unable to respond " no'^ to an ordi- 
nary question blurts out the monosyllable w4ien the question is so 
worded as to provoke his anger. Dr. Broadbent reports a case in 
which the power of voluntary speech was entirely lost, but in 
which under emotion a large number of words would be forced 
out rapidly like so many interjections. Brown-S^quard states 
that aphasic persons sometimes recover their speech during de- 



DISORDERS OF MEMORY AND CONSCIOUSNESS. 363 

Hrium, and Jackson relates an instance from the experience of 
Langdon Down in which a speechless idiot during the delirium 
of fever spoke freely. 

When the aphasic has habitually spoken more than one lan- 
guage, certain words may remain in each language. Thus, a 
woman under my own care would frequently answer " no'^ as the 
only English word at her command, but would express her emo- 
tion by " Gott in Himmel/^ the sole remaining fragment of her 
native tongue. 

Functional Aphasia. — Although commonly an aphasia is due to 
an organic lesion, yet it may be purely functional. It is notorious 
that under great excitement the power of speech may be lost. In 
the BosL 3Ied. and Surg. Journ., December 17, 1885, is an account 
of a case in which aphasia was produced in a child by fright. In 
hysteria aphonia is much more frequent than aphasia, and yet 
undoubtedly there is an hysterical aphasia which may remain for 
many months, if not years, although not dependent upon any gross 
lesion of the brain. Dr. Haertz [Ziemssen^s Cydopcedia, vol. ii. p. 
601) states that a paroxysm of aphasia may replace the ordinary 
symptoms of malarial poisoning. After epileptic attacks there is 
sometimes a temporary aphasia. The symptom has also been 
noted in a large number of acute diseases, but probably in the 
majority of these cases it has rested upon a distinct lesion. It is 
certainly capable of being produced by reflex irritation. Prof. 
Bernhardt affirms that in children indigestions, entozoa, and psy- 
chical irritations occasionally produce aphasia {London Medical 
Record, October 15, 1886). Kussmaul states that cases have been 
reported in which collections of faeces in the large intestine or lum- 
bricoid worms have been supposed to be the cause of an aphasia 
which has disappeared on the expulsion of the irritant. In a case 
which came under my notice several temporary attacks of aphasia 
were the result of an overloaded stomach, and were relieved at 
once by vomiting. 

Functional aphasia can usually be distinguished from the 
organic affection by its temporary or paroxysmal character, but 
in hysteria the loss of speech may persist for a great length of 
time. Under these circumstances the positive diagnosis may long 
be impossible, although the nature of the aphasia may be surmised 
from the hysterical history of the patient and the absence of evi- 



364 DIAGNOSTIC NEUROLOGY. 

dences of serious organic brain-disease. The sudden recovery of 
such a case would decide its nature. 

Lesions of Aphasia. — In 1836, Dr. Dax first made known at 
Montpellier that in organic aphasia the left cerebral hemisphere is 
at fault. Since his earliest publication a large number of cases have 
been reported, which prove that in the great majority of instances 
it is the left hemisphere that is diseased : thus, out of two hun- 
dred and sixty cases of aphasia collected by Dr. Seguin, of New 
York {Quarterly Journal of Psychological Medicine, January, 
1868), in two hundred and forty-three there was right hemi- 
plegia and in seventeen left hemiplegia, the proportion being as 
14.3 is to 1. 

The connection between disease of the left hemisphere and 
aphasia is even closer than is indicated by these figures of Dr. 
Seguin, for there is reason to believe that in a considerable pro- 
portion of the cases in which left hemiplegia has been associated 
with aphasia there have been two lesions. The most satisfactory 
explanation of this connection yet given is the superior develop- 
ment of the left cerebral hemisphere, due to the habitual exces- 
sive use and training of the right hand, which acts not only upon 
the individual, but, from the laws of heredity, upon the race, the 
perpetual training of generation after generation resulting in an 
habitual excessive development of the centres presiding over the 
right hand, — i.e., of the left cerebral hemisphere. Especially is 
the habitual act of expressing thought in writing with the right 
hand believed to lead to the great development of the speech- 
centres in the corresponding brain-region. In a certain propor- 
tion of cases the human individual is born with a superior devel- 
opment of the left hand, or, in common parlance, is left-handed. 
In such persons it must be acknowledged that the right cerebral 
hemisphere is the most highly organized. If the theory which 
'has just been enunciated be correct, we should expect to find 
that aphasia in left-handed people is habitually associated with 
left hemiplegia. 

Drs. Pye Smith, Hughlings-Jackson, and John Ogle have re- 
ported a number of such cases. (See Kussmaul, p. 740.) In a 
very extraordinary case reported by Wadham, a young man, who 
wrote with his right hand, but was, like his brother, in other re- 
spects left-handed, suflFered with left hemiplegia with aphasia. It 



DISORDERS OF MEMORY AXD CONSCIOUSNESS. 365 

would seem, therefore, that he used the left hemisphere in writing 
and the right in speaking. In this case, according to Dr. Bate- 
man (see London Lancet, April, 1880), the lesion found after 
death was a complete destruction of the island of Reil on the 
right side, the left hemisphere of the brain being healthy. The 
association of aphasia with left hemiplegia is usually dependent 
upon its occurrence in left-handed people, but this explanation 
will not suffice for all cases. Thus, Dr. Michel Catsaras [La 
France Med., 1884, vol. ii.) reports a case of complex aphasia 
with left hemiplegia in a man who was not left-handed. Hugh- 
lings-Jackson [London Lancet, April 24, 1880) has recorded a 
similar case. I have not been able, however, to find any case of 
the character just spoken of in which there has been an autopsy, 
and the possibility remains that in these cases a double lesion has 
existed. Even if, however, an exceptional case should be clearly 
made out, it would have to be viewed simply as an exception to 
the general law, that the speech-centres of the left hemisphere are 
active, whilst those of the right hemisphere are dormant. 

The connection between the frontal lobes and word-thought was 
originally pointed out by the celebrated Prof. Goll in 1825. His 
pupil Bouillaud located the speech-centres in the divisions of the 
cerebrum over the fissure of Sylvius and in front of the fissure 
of Rolando. In 1861, Broca affirmed that the integrity of the 
left third frontal convolution, and perhaps also of the second, 
is essential for the development of articulate speech. The cases 
of organic aphasia which have been reported in the last twenty 
years are far too numerous for analysis here. They undoubt- 
edly, however, show that the third frontal convolution and the 
island of Eeil in the left hemisphere are closely connected with 
the speech-function. The conclusion reached by Kussmaul is 
that the left frontal lobe, and especially the third frontal convo- 
lution, possess by no means a monopoly of aphasia, although it is 
most frequently brought about by lesions at this point. The 
island of Reil comes next in frequency to the frontal lobe. 

It seems to me that we must consider it proved that perma- 
nent complex cortical aphasias are due to disease of the third 
frontal convolution or the island of Reil in the left hemisphere, 
and that in this position are located the centres of word-thought. 
Kussmaul states that he has been able to discover only two ob- 



366 DIAGNOSTIC NEUROLOGY. 

servations in literature in which a lesion of the third left con- 
volution has occasioned no aphasia, and that in the reports of 
these cases it is not stated whether the patient was right-handed. 
It has not been the habit of most observers to examine micro- 
scopically the convolutions of the island of Reil in cases of aphasia 
without apparent lesion, and without such examination no weight 
can be attached to a case in which aphasia has existed without 
lesion of the speech-convolutions. In one case of ray own, in which 
to the naked eye the speech-convolutions were healthy, the micro- 
scope showed that their vessels had undergone degeneration and 
the cells atrophy. I have also had opportunity to examine speci- 
mens from an unreported case which occurred in the practice of Dr. 
A. V. Meigs, in which the only gross lesion found was a large patch 
of softening in the neighborhood of the left corpus striatum, but in 
which the microscope showed that the blood-vessels and ganglionic 
cells of the third frontal convolution were profoundly affected, 
there being even minute patches of softening and microscopic 
hemorrhages. In the light of such cases as these the scientific 
accuracy of much of our aphasic literature becomes very doubtful, 
and I do not think that there is a properly-observed case on 
record in which a permanent aphasia has existed and the third 
frontal convolution region been normal. If such a case should be 
reported, the aphasia would have to be considered as due to an 
anatomical variation or as produced in some indirect way. It is 
well known that the effects of gross lesions of the brain often ex- 
tend far beyond their immediate confines, and if a gastric irritation 
may inhibit the action of the speech-centres, it is not strange that 
a tumor or softened mass of brain-tissue may sometimes have a 
similar power. It must also be remembered that aphasia should 
be produced by lesions of the white matter w^hich interrupt the 
passage downward of the fibres from the speech-centres. 

In regard to word-blindness and word-deafness, the number of 
autopsies which have been made is not as yet sufficient to allow us 
to consider the conclusions reached as fixed. The centres for 
sensory aphasia are located by Wernicke along the margin of the 
fissure of Sylvius in the first temporal convolution. The region 
of sensory aphasia is, however, probably a much wider one. 
Grasset (Montpellier Medical, 1884, p. 52) makes three central 
positions for the aphasic alterations : 



DISORDERS OF MEMORY AND CONSCIOUSNESS. 367 

First Centres of verbal deafness in the first left temporal con- 
volution. 

Second. Centres of verbal blindness in the inferior parietal 
lobule. 

Third, Centres of transmission, or ataxic aphasia, at the foot 
of the third temporal convolution. 

Dr. Amidon {New York Medical Record, November 15, 1884) 
collected twenty- four cases of sensory aphasia: in eight, with 
lesions affecting the visual and auditory regions of the left hemi- 
sphere, there were both word-blindness and deafness; in two, 
in which the area of vision alone was affected, there was word- 
blindness; in fourteen, with the lesion in the auditory region, 
there was word-deafness. Wernicke locates the lesion in para- 
phasia in the medullary tract connecting the sensory aphasic 
region with the island of Reil. In a case reported by Dr. S. G. 
Webber [Boston Medical and Surgical Journal, December, 1883) 
the hemorrhage was situated so close to this tract as to act readily 
upon it by pressure. In this case the recovery of the speech- 
function during life showed that the effect of the lesion was tem- 
porary, and therefore probably an indirect pressure-effect. 

The course of the fibres which run from the speech-centres of 
the frontal lobe is not known ; undoubtedly, however, a clot in 
the neighborhood of the claustrum, which does not directly impli- 
cate the centres, will produce aphasia, probably by dividing con- 
ducting fibres and isolating the centres. I have made autopsies 
upon two such cases, and Drs. Farge, Popham, and Jaccoud have 
each reported similar instances. 

The lesion of aphasia varies greatly in its nature. It may be 
a clot, a tumor, an abscess, — indeed, any form of acute or chronic 
localized alteration of the brain-substance. Very frequently it is 
a narrowly-defined, syphilitic, gummatous meningitis. The ar- 
terial supply of the convolutions is received through terminal 
branches which pass through the pia mater and do not anas- 
tomose: hence an excessive thickening or inflammation of the 
membranes may so interfere with the circulation in the cortex as 
to affect its function. In this way are to be explained at least 
some of the cases of aphasia without obvious lesion of the tem- 
poral convolutions. 

In a large proportion of the cases of aphasia the lesion is 



368 DIAGNOSTIC NEUROLOGY. 

embolic. The region of the brain involved is supplied by the 
middle cerebral or Sylvian artery, the line of whose course so cor- 
responds with that of the carotid arteries that the blood-current 
is very likely to carry into it any foreign matters which may reach 
the brain. The Sylvian artery on the surface of the island of 
Reil divides into four branches : of these, the first is distributed 
to the outer portion of the orbital surface of the hemisphere and 
the adjacent inferior frontal convolution; the second supplies the 
chief part of the second ascending convolution ; the third passes 
through the fissure of Rolando to the remainder of the ascending 
frontal convolution, to the ascending parietal convolution, and to 
the inferior part of the superior parietal lobule; the fourth branch, 
lying in the posterior part of the fissure of Sylvius, supplies the 
inferior parietal lobule and the superior temporo-sphenoidal con- 
volution. 

The three speech-centres of Grasset, although conjointly sup- 
plied by the middle cerebral artery, are reached by distinct 
branches of this artery, so that whilst an arterial lesion of the 
main trunk involves all the speech-centres and gives rise to a 
complex aphasia, a lesion of one of the branches may involve 
either of the aphasic regions separately and give rise to one of 
the special forms of the affection. 

In children aphasia sometimes exists without hemiplegia. It 
may be due to an arrest of development, which, I believe, may 
be caused by an emotional storm. A case which died under my 
care had the history of the child^s having been well and strong 
until it was nearly two years old, at which time it was beginning 
to talk successfully. It was then taken into a railway-train, was 
excessively frightened, and screamed for two hours. From this 
time it ceased to talk, developed convulsions, and, after several 
years, died. At the autopsy the only lesion I could find was com- 
plete failure of development of the convolution of the left island 
of Eeil. The brain looked as if this had been abruptly gouged 
out of it. 

GENERAL MEMOEY. 

Like most functions of the organism, memory may be stimu- 
lated, perverted, or depressed. 

Exaltation of Memory, — A distinct, indisputable stimulation 



DISORDERS OF MEMORY ANT> CONSCIOUSNESS. 369 

or increase of the memory under the influence of pathological 
processes is a phenomenon rarely to be distinctly recognized. 
Forbes Winslow details cases in which an extraordinary excita- 
tion of the memory and of other mental functions preceded an 
attack of apoplexy ; and it is probable that in the mental exalta- 
tion which precedes a general mania or occurs in the peculiarly 
dangerous form of insomnia due to excitation of the cerebral 
cortex the memory may share in the general functional excite- 
ment of the brain. 

Failure of Memory,— Ijoss of memory is an exceedingly fre- 
quent symptom 'of organic brain-disease. It cannot be said to 
be characteristic of any particular form of brain-disease, but is 
liable — indeed, almost certain — to occur in organic affections of 
the cerebral cortex. Its diagnostic importance comes from the 
fact that, unless due to obvious acute disease or connected with 
insanity, it is a strong indication of an organic affection of the 
brain. A degree of failure may, however, arise from simple 
brain-exhaustion. 

Usually the patient or his friends recognize even a slight loss 
of memory ; but sometimes very careful search is required for its 
discovery. Under these circumstances the physician must question 
the patient as to the small events of the last twenty-four hours, 
and not be misled by that vividness of recollection of the long past 
which sometimes causes the sufferer to declare that his memory is 
even stronger than normal. In doubtful cases of general paralysis 
of the insane, failure of the memory is of special value in en- 
abling us to distinguish the organic insanity from functional 
mental disturbances which may simulate it. According to my 
own experience, failure of memory which is not accompanied by 
paralysis for the time being of all the functions of the mind, as in 
insanity, is of serious import in proportion to its completeness. 

CORRELATED DISORDERS OP MEMORY AND CONSCIOUSNESS. 

As has already been stated, a memory is possessed by all va- 
rieties of ganglionic nerve-cells, but that intellectual function to 
which the name is usually restricted is so closely related with 
consciousness that we can scarcely conceive of its existence with- 
out consciousness : nevertheless, the connection of memory with 
dreaming shows that it is a separate function from consciousness. 

24 



370 DIAGNOSTIC NEUROLOGY. 

There are a good many reasons for believing that the impres- 
sions of all events with which an individual has been con- 
nected are indelibly recorded upon his brain-tissue, although 
he may not be able to bring such impressions into conscious 
perception. At the approach of death, or under the stimulation 
of disease at a time when consciousness is wanting, persons will 
frequently speak in foreign tongues, recite passages of prose or 
poetry long since forgotten, or give detailed accounts of events 
that occurred in their earliest childhood and of which they 
have in their normal condition not the sh'ghtest remembrance. 
It would therefore appear that two distinct functions or acts 
are involved in conscious memory, — one the preservation of the 
records, the other the dragging out of such records into the 
light of consciousness and their recognition by the personality of 
the man. In certain diseases when consciousness is obliterated 
the connection between the stored records of the cerebral cortex 
and the automatic speech-centres is so close that the latter act 
in obedience to the records, and the unconscious patient speaks in 
an unknown tongue, or relates occurrences of which he has no 
conscious memory. 

When the link that binds consciousness to memory is broken 
by disease, consciousness may exist without memory. Under 
these circumstances consciousness is isolated from the past, al- 
though the past may still be connected with the present by an 
automatic unconscious memory. 

This is illustrated by the case (Ross, Nervous Diseases, vol. 
ii. p. 880) of a man who was wounded during the Franco-German 
war in such a way as to lay bare the brain for about two and a 
half inches in the left parietal region. As the result of this he 
was subject to attacks lasting from twenty-four to forty-eight 
hours, in which, although in a condition of apparent partial con- 
sciousness, he had no sensitiveness of any part, and was unaware 
of physical pain. Nevertheless, his will was at once influenced 
by external objects. If set upon his feet, the contact with the 
ground started him to walking, when he marched straight on, 
quite steadily, with fixed eyes and without saying a word. If 
he met with an obstacle, he would touch it and try to make out 
what it was, and then get out of its way. A pen placed in his 
hand started him to writing. Dr. Ross says of him, — 



DISORDERS OF MEMORY AND CONSCIOUSNESS. 371 

^' Give him cigarette-paper and he will take out his tobacco, 
roll a cigarette^ and light it with a match from his own box. But 
ignite a match yourself and give it him, he will not use it, but 
let it burn between his fingers. If his tobacco-box be filled with 
any trash, he will roll his cigarette and smoke without perceiving 
the hoax. If a pair of gloves be put into his hand, he will put 
them on, and, being reminded of his profession, will look for his 
music. If a roll of paper then be given to him, he will assume 
the attitude of a public performer and begin to sing.'^ 

Loss of Personal Identity. — An attribute of the human under- 
standing which is dependent upon the existence of memory and 
consciousness is the sense of personal identity, — i.e., the conviction 
of the individual that he is the same person as he has been in the 
past. The unbroken chain of events recorded from an indefinite 
past correlated with the consciousness of the present gives the 
realization of the unity of the present with the past. This sense 
of personal identity is destroyed by a complete loss of memory, 
which loss may be abrupt and be unaccompanied by impairment 
of consciousness or of rationality. I have seen this association of 
symptoms continue for several days after a sunstroke, so that the 
patient, who had been brought by ambulance into the hospital, 
was unable, after he had recovered his mental faculties and was 
perfectly rational, to give any clue to his personality which could 
lead to his identification. 

Double Personality. — Hasheesh and perhaps some other drugs 
have the power of producing a sense of double personality, — a 
condition in which the subject feels as though he were two dis- 
tinct personalities, one holding intercourse continually with the 
other. In insanity this feeling of double personality may be the 
basis of delusion. Such delusion usually takes the form of an 
absolute belief in a dual existence : thus, in a case of my own, an 
insane man believed that he and all others of the human race had 
their ^^ doubles," which were not to be distinguished from their 
proper personalities. The life of the patient was overwhelmed 
by the constant fear that he was not himself, but his own double. 

Double Consciousness. — Double personality is to be distinguished 
from the extraordinary phenomenon to which the names of double 
consciousness, periodic failure of memory, and periodic amnesia 
have been given. In this state there is undoubtedly a disorder 



372 DIAGNOSTIC NEUROLOGY. 

of memory, but in most cases all the intellectual functions are 
deeply involved. Before attempting an analysis of double con- 
sciousness I shall briefly sketch some of the more important re- 
corded instances. The earliest record of such a case that I have 
been able to find is by Dr. Mitchell {Med. Repos,, p. 185, New 
York, 1817). A very highly educated young woman fell without 
warning into a deep sleep, which lasted for many hours. On 
waking, she had lost all her former knowledge ; her memory had 
become a tabula rasa, every trace of her past culture having dis- 
appeared. It was necessary for her to relearn everything. After 
extreme effort she became familiar with surrounding persons and 
things, acquired the alphabet, then learned to read, then to wa^ite, 
and finally to reckon. Some months later she again fell into a 
deep sleep, and awoke in her normal state. She now knew all that 
she had learned in her original condition. For many years after 
this she alternated between the first and second conditions, in 
each state knowing only what she had learned in the previous 
periods of the same state. When she made acquaintances she 
recognized them again only when she was in the state in which 
she had been at the time of the first meeting. Her handwriting, 
which was very good in her first condition, was very bad in her 
second state. 

Dr. Azam (Annales 3Ied,'Psych,, 1876, vol. xvi.) reports a case 
of double consciousness occurring in an hysterical girl. In this 
patient the change from one state to the other was always pre- 
ceded by a profound sleep lasting three or four minutes, this 
period of repose being ushered in by an intense headache. In 
her abnormal state the girl was extremely gay and vivacious, 
and remembered perfectly all that had passed both during pre- 
vious similar abnormal conditions and during her normal life. 
There was no delirium, no hallucination, no false appreciation, 
but the intellectual faculties were more developed than during her 
normal condition. After this condition had lasted a variable length 
of time, her gayety suddenly disappeared, her head dropped, and 
she fell into a deep sleep, out of which she awakened in a con- 
dition of great sadness. She forgot all those things that had 
happened during her abnormal period, but remembered perfectly 
everything that she had known or that had been done during the 
preceding normal states. Having been seduced and become preg- 



DISORDERS OF MEMORY AND CONSCIOUSXESS. 373 

nant during one of her abnormal periods, she was entirely ignorant 
of the aflFair during her normal state, although fully aware of 
it during successive abnormal periods. Finally, while in her 
normal condition she was made to understand that she was preg- 
nant, when she was seized with violent hysterical convulsions. 
After the birth of the child she had no mental trouble for several 
years, and was married. Somewhat later, after a very painful 
and exhausting accouchement she had hysterical lethargy, followed 
by ecstasy and violent hysterical manifestations. At thirty-two 
she was the mother of a family, and an active business woman. 
The child which had been conceived during an abnormal period 
was very intelligent, and an excellent musician, but of a highly 
nervous temperament, and liable to nervous attacks. 

A case somewhat similar to this is reported by Dr. James Mayo 
{London Medical Gazette, vol. i., 1845). A young girl passed re- 
peatedly through two alternating diflPerent states of mental exist- 
ence. During the abnormal periods she was extremely excitable, 
and had mental attributes much above her normal condition. She 
made progress in needle-work and in intellectual acquirements 
far beyond what was possible with her natural talent. She also 
became very vivacious in conversation, but did not recognize her 
relations to her father and mother, calling them by wrong names. 
On the subsidence of her abnormal state her recollection of 
kindred and friends returned, and she resumed her quiet, dull 
character. In the abnormal state she remembered without the 
slightest confusion all that had happened in previous abnormal 
periods, and what she had learned either manually or intel- 
lectually, but knew nothing of what had occurred in her normal 
conditions. In her normal conditions she had no knowledge of 
anything that had happened or of anything that had been 
learned during the abnormal states. 

I have seen one case which offered symptoms resembling those 
of double consciousness. They were produced by a depressed frac- 
ture caused by a blow upon the head. Previous to trephining 
there were at least four of the abnormal states, but since the oper- 
ation, over a year ago, there has been no return, although the 
patient's mental condition is not good. In the first of his spells 
he went to a railroad-d^pot, bought a ticket, travelled on the cars 
two or three hours, and, after getting out, met an acquaintance, 



374 DIAGNOSTIC NEUROLOGY. 

who expressed great surprise at seeing him, and asked why he had 
come, receiving the reply that he had come to try to get work. 
The man then went to a friend^s house to dinner, where he talked 
and ate, until suddenly he waked up, with an inquiry of intense 
surprise as to how he had got there. He appeared to have no 
recollection of his trip, except of a few minutes, his remem- 
brance of which was so vivid as to indicate that he had then had 
a waking spell. During the abnormal period the man's beha- 
vior suggested to his acquaintances only that he was distraught. 
I was unable to obtain evidence that he exhibited during the spells 
any memory of acts performed in previous similar periods. 

It does not seem necessary to abstract any more of the few 
recorded cases of double consciousness for the purposes of pres- 
ent illustration. In a typical case there is, first, an abrupt loss 
of memory at the beginning of each paroxysm for everything 
that has happened during paroxysms not of the same series ; 
secondly, a change in the personal character of the individual, 
the disposition, the habits of thought, and even the intellectual 
powers being altered. 

Double consciousness may exist in various degrees. Thus, in 
a case reported by Dr. Samuel Jackson (Amer, Jour. Med. Sci., 
1869, p. 18), the character was affected rather than the memory. 
An hysterical young lady was attacked with nausea and vomit- 
ing, followed by a complete alteration of character and change of 
voice. Formerly mild and gentle, she became abrupt and rude, 
and yet would so perform her household duties that it was often 
difficult to determine in which condition she was. The attacks 
came on daily, without apparent cause. The symptoms in this 
case seem to represent only an exaggerated form of moodiness; 
and there can be no doubt that even the most complete double 
consciousness is closely related on the one hand to epilepsy and 
on the other to hysteria and to insanity. In my case detailed 
above, the cause of the attack was a blow upon the head, — a not 
rare cause of epilepsy, — and there was no binding memory between 
the spells. In that form of epilepsy in which there are auto- 
matic movements, and also in cases of epileptic delirium, the 
paroxysm is in many ways related to the second period of double 
consciousness, but differs in that the individual does not preserve 
any reasonableness or capability of being affected by other persons, 



DISORDERS OF MEMORY AND CONSCIOUSNESS. 375 

and does not remember what has occurred during previous spells 
of similar type. On the other hand, in a large proportion of the 
cases, double consciousness has occurred in hysterical women, and 
the phenomena pass almost insensibly into those of hysterical 
semi-consciousness and delirium. 

In insanity there is often a change in the whole manner of 
thought and character of the individual. In a case of melancholia 
long under my care, the patient after recovery was subject to fre- 
quent attacks of transitory melancholia, which lasted from a few 
to many hours : whilst perfectly contented and happy, she would 
say, "It is coming,^^ and in a few moments would be covered over 
as it were with a wave of emotional depression which would, for 
the time being, completely alter her habits of thought and her 
behavior. In a case of profound apathetic melancholia recently at 
Burn Brae Asylum, near this city, the patient one day suddenly 
said, "I have had a revelation: my sins are forgiven me,^^ and, 
after weeks of absolute voicelessness, became talkative, rational, 
and active in all his sympathies, without, however, being unduly 
excited. Not long after this the man relapsed into his insane 
condition. It is said that similar sudden changes have pre- 
viously occurred several times. This man appears to carry his 
memory over from one state to the other, and in this only do his 
symptoms differ from those of typical double consciousness. If 
in such a case of insanity as this the continuity of memory should 
be broken, there would be a typical double consciousness. 

The close relation between insanity and double consciousness 
is further illustrated by a case reported by Dr. David Skae, in 
which a man after eighteen months of typical melancholia de- 
veloped a twofold life, being on alternate days sane and insane. 
On melancholic days he neither eats, sleeps, nor walks, but sits 
incessantly turning the leaves of the Bible and complaining 
piteously of his misery. At this time he has no remembrance 
of the days in which he is well, nor of any engagements made 
during them : he does not, and cannot be made to, recognize the 
existence of such days, but contemplates the future with hopeless 
despondency. On the alternate well day he denies that he has 
any cause of complaint, believes that he was well the previous 
day, transacts business, takes food and exercise, and is entirely 
free from delusions or despondency. He also anticipates no 



376 DIAGNOSTIC NEUROLOGY. 

return of his illness, and has no memory of his bad days. He 
remembers exactly the transactions of his previous well days, 
and persists in making business engagements for the following 
day, — i.e., for his melancholic day, — although repeatedly assured 
that at the time named he will be unable to attend to business. 

There is a very rare mental condition known by German 
writers as Doppeltwahrnehmung, or double perception, which is 
liable to be confounded with the condition I have just described 
under the name of double consciousness. The peculiarities of 
this- aiFection are well portrayed in the report by Dr. M. Rup- 
pert [Allgemeine Zeitschrift fur Psychiatrie, 1869, vol. xxvi. p. 
531) of a case in which whenever the man read to himself he 
would plainly hear each word repeated as though a chorus of 
fifty or sixty female voices were speaking to him, and when he 
ceased to read he would hear the last words read after him. 
This reading after him disappeared as soon as he spoke aloud, 
and was prevented by his reading aloud. In one sense of the 
term consciousness, this patient had a double consciousness ; but 
it is plain that his symptoms were much more closely related 
to hallucinations than to the state commonly known as double 
consciousness. 



CHAPTER X. 

DISORDERS OP CONSCIOUSNESS. 

In a book like the present an elaborate discussion of the so- 
called physiological theories of sleep would be out of place. It 
seems to me, however, that a few words upon the subject are 
required. According to some physiologists and neurologists, 
natural sleep is induced by the withdrawal of blood from the 
brain. It must be allowed that the concordant results of experi- 
ments show that during sleep there is a more or less pronounced 
cerebral anaemia, which on awaking is replaced by turgescence 
of the cerebral vessels. This is not, however, proof that sleep 
is induced by the withdrawal of the blood. It is a universal law 
that cessation of functional activity is immediately followed by 
lessening in the amount of blood in the part. I conceive, there- 
fore, that the sleep is the cause of the bloodlessness, and not the 
bloodlessness the cause of the sleep. This is certainly in accord 
with clinical experience, which to my mind proves that insomnia 
may be connected either with excessive anaemia or with excessive 
congestion of the cerebral cortex. Thus, the wakefulness of 
anaemia is well known, as is also the insomnia of acute mania. 
Some physiologists have attempted to explain the production of 
sleep by supposing that certain chemical compounds are formed 
during the activity of the day, which, circulating in the blood of 
the brain, act as hypnotics on the cerebral cells. There is no evi- 
dence worthy of attention establishing any theory of this character, 
and to my thinking such chemical theories are upon their face so 
improbable that they should be received only after the clearest 
proof. Concerning sleep, as concerning other functions of the 
human organism, the simplest explanation is the most probable. 
In the greater portion of the active tissues of the organism rest 
alternates with activity, and the brain in its sleep conforms to this 
general habit. The best explanation of sleep, then, is that when 
exhausted by eflFort the cortical brain-cells pass into a condition of 
functional inactivity, during which their power of further effort is 

377 



378 DIAGNOSTIC NEUROLOGY. 

recuperated. Because consciousness is the expression of functional 
activity in these cells, therefore when these cells do not exercise 
their function there is unconsciousness, — Le,, sleep. That sleep, 
or functional rest, should be more or less periodical seems essential 
from the very nature of the case. Throughout a healthy nervous 
system a tendency to periodicity of action is marked. In disease 
this tendency becomes even more apparent. Pain-storms recur 
with more or less regularity, habits of periodical discharge, at first 
accidental, become fixed, convulsions develop at intervals, etc. 
The daily rhythm in the production and dissipation of animal 
heat during health is a forerunner of the marked diurnal swing 
of temperature so common in fevers. 

The bearing upon the practice of medicine of our belief as 
to the immediate causation of sleep is very apparent. If we 
think that insomnia is due to cerebral anaemia, we must treat the 
anaemia to remove the insomnia. Out of such error have grown 
other theories, which, though absurd, have been largely dominant. 
A notable example of these is the belief, at one time wide-spread, 
that bromide of potassium produces sleep by affecting the blood- 
vessels. Again, largely in order to sustain their theories, certain 
neurologists have distinguished sleep, stupor, and coma as essen- 
tially diverse conditions readily to be diagnosed in the sick-room. 
These states are, however, simply the outcome of different de- 
grees of completeness in the suspension of the functions of the 
cerebral cortex : such a suspension finds its lightest expression in 
a doze, and its profoundest development in a coma. No rules of 
diagnosis can be laid down which will enable us to draw any 
practical lines, sharp and fixed, between the lightest slumber and 
the most complete unconsciousness. Nor is the unconsciousness 
of anaesthesia an isolated thing. It is simply a suspension of 
cerebral function in which a chemical agent is the cause of the 
paralysis. In the sick-room every grade can be found between 
light and heavy slumber, between heavy sleep and stupor, and 
between stupor and coma. For the purposes of discussion we 
must, however, arbitrarily separate these states. I would define 
these terms as follows : sleep is that condition of unconsciousness 
in which the subject is readily aroused, and when aroused is easily 
kept awake by ordinary external stimulations or by his will-power; 
stupor is that condition in which the subject is aroused with great 



DISORDERS OF CONSCIOUSNESS. 379 

difficulty, and when left to himself relapses into unconsciousness ; 
coma is that state in which it is impossible by external irritation 
to restore consciousness. 

In the present chapter I propose to treat of, first, sudden loss 
of consciousness ; secondly, sleep, its abnormalities and accidents. 

SUDDEN LOSS OF CONSCIOUSNESS. 

Sudden loss of consciousness is a symptom of such varying im- 
port that it is scarcely susceptible of scientific arrangement iii a 
treatise like the present. Nevertheless, it is one of such practical 
importance as to demand discussion. A blow upon the head, or 
even upon a distant part of the body, may produce immediate 
insensibility ; but the study of such cases belongs to surgery, and 
I shall in the present consideration of the causes and collateral 
symptoms of sudden unconsciousness omit traumatism and its re- 
sults. Loss of consciousness is an essential part of the epileptic 
convulsion ; but, as this convulsion has already been studied in 
detail, I shall at present consider only affections in which there 
are no convulsive symptoms, or in which if the convulsion occurs 
it is not an essential feature of the disease, but an incident of the 
attack. Thus, in epilepsy the convulsion is an essential feature, 
but in a cerebral hemorrhage or a sunstroke it is not of such 
character ; and if a convulsion occur in an apoplexy it belongs 
to the individual case, because it is not necessarily present in the 
disease. 

The ordinary non-traumatic causes of the sudden loss of con- 
sciousness are epilepsy, hysteria, syncope, sunstroke in its various 
forms, apoplexy, various forms of poisoning, and malignant sys- 
temic diseases. 

The symptoms which attend the hysterical and the epileptic loss 
of consciousness, and the methods of recognizing the nature of such 
attacks, have been thoroughly discussed in a previous chapter. 
Syncopal loss of consciousness, due to a failure in the supply of 
blood to the brain, is to be recognized by the extreme pallor of the 
subject, by the absence of the pulse, or its excessive threadiness 
or weakness, at the wrists, and by the greatly enfeebled action of 
the heart, as shown by the weakness of the cardiac sounds and 
impulse. Its diagnosis is facilitated by noting that it occurs after 



380 DIAGNOSTIC NEUROLOGY. 

exertion or during great excitement, and in a subject already- 
enfeebled by disease, hemorrhage, or accident, or else of a natu- 
rally weak constitution. 

Sunstroke. — During the summer months sunstroke is a very 
frequent cause of sudden loss of consciousness. It develops 
only after exposure to heat, either natural or artificial. It may 
happen in the day or in the night, and is especially fatal in sugar- 
refineries and other places where the heated air is saturated with 
moisture. It occurs most frequently in unacclimated races, and 
is very rare in negroes, Hindoos, and other tropical peoples. 
There are two distinct forms of it, — one of which may be known 
as thermic fever, the other as heat-exhaustion. 

The animal organism is constructed to run upon a certain plane 
of heat, and whenever this level is departed from all the functions 
of the body suffer. The nervous system is the most susceptible 
portion of the organism, and therefore the nervous symptoms are 
always prominent when there is a great disturbance of the bodily 
temperature. It appears to make little difference whether the tem- 
perature be elevated above or depressed below the norm, so far as 
the nervous system is concerned. In either case, if the departure 
from the norm be sufficient, consciousness is lost, the lower brain- 
functions are implicated, so that the respiratory and cardiac action 
both become irregular, and death occurs at last usually from 
paralysis of the respiratory functions. In thermic fever the tem- 
perature of the body is greatly elevated. In heat-exhaustion 
the bodily temperature is depressed. 

Heat-exhaustion is very often felt in a mild degree by feeble 
workers in hot weather. There is a sense of weariness and 
distress, pallor of the countenance, failure of the muscular 
force, and finally failure of the pulse. Severe examples of the 
affection are rare. In these the symptoms may develop almost 
as suddenly as in thermic fever. Thus, in a case brought into 
the Centennial Hospital during my service in 1876, there was 
sudden unconsciousness, with muttering delirium ; great rest- 
lessness; a facial expression of collapse; profuse perspiration 
bedewing the whole surface ; rapid, feeble, scarcely perceptible 
pulse; and a mouth-temperature of 95°. Although in their 
general aspect the symptoms of heat-exhaustion resemble those 
of thermic fever, the true character of the case should be at 



DISORDERS OF CONSCIOUSNESS. 381 

once recognized on touching the ice-cold surface of the body. 
The only disease or condition readily confounded with heat-ex- 
haustion is collapse from other causes. I have seen cases of in- 
ternal aneurism, of pernicious malarial fever, and of other aflFec- 
tions picked up in the streets and brought into the hospital in 
collapse in which a mistake in diagnosis would have been very 
excusable. If such a case should happen upon an intensely hot 
day, and the bodily temperature be much below the norm, the 
diagnosis might have to be reserved. Except as regards pernicious 
malaria, however, this is a matter of little importance, because 
the treatment of heat-exhaustion is the same as that of collapse 
with lowered temperature from other causes. 

ThermiG fever, heat fever, or coup de soleil (sunstroke) usually 
comes on without distinct prodromes, although frequently there is 
a great sense of distress or of a general burning heat before the 
loss of consciousness, which may also be immediately ushered in 
by chromatopsia, or colored vision, — the whole landscape being 
deluged in a blue, yellow, or red light. The unconsciousness 
ordinarily develops abruptly, and is complete, although very fre- 
quently it is associated with muttering delirium. There is usually 
great muscular restlessness, which in some cases becomes convul- 
sive or is replaced by violent epileptiform convulsions. Some- 
times the patient is profoundly relaxed and quiet. The sur- 
face of the body, at first dry, often later in the attack gathers 
upon itself an excessive perspiration, which does not, however, 
reduce its burning heat. The face is flushed, and the eyes are 
suffused. The rapid pulse is sometimes bounding and apparently 
strong, although almost invariably compressible ; frequently it is 
feeble and even thready, especially if the symptoms have lasted 
for some hours. Vomiting is very common ; purging is in bad 
cases almost always present. The whole body is apt to exude 
a peculiar odor, which is especially strong in the fsecal discharges. 
The characteristic symptom is the high temperature, which, as 
measured in the mouth or rectum, may reach 112° or 113°, and 
is rarely below 108° in cases severe enough for unconsciousness to 
be present. The urine is scanty, sometimes albuminous, not rarely 
finally suppressed. The breathing is more or less labored, and 
often irregular, and towards the last generally becomes more and 
more shallow. Although at times the patient suffering from 



382 DIAGNOSTIC NEUROLOGY. 

thermic fever may be partially aroused by shouting, shaking, etc., 
the unconsciousness is often absolute. The pupils are variable, 
sometimes contracted, sometimes dilated. 

The diagnosis of this form of thermic fever is usually free from 
difficulty : the known exposure to heat, — i.e., to the cause of sun- 
stroke, — the unconsciousness, and other symptoms, and the very 
high temperature both of the surface and of the interior of the 
body, are characteristic. If, however, an apoplexy should occur 
upon a very hot day and be, as it might, associated with a sudden 
rise of temperature, the diagnosis would not be easy; indeed, if 
the mouth were not drawn and the general relaxation prevented 
the recognition of hemiplegia, the diagnosis might be impossible. 

In this country the profession has been accustomed to recognize 
as sunstroke, or thermic fever, only the severe cases w^hich approach 
to the symptoms that have just been detailed. For many decades, 
however, medical practitioners in India have known that there is 
a form of continued fever due to heat which, under treatment, 
may gradually subside, or which may at any time end in a sud- 
den explosion like that of true sunstroke. Dr. John Guit6ras 
(Therapeutie Gazette, March, 1885) has shown that this mild form 
of thermic fever occurs in the subtropical portions of the United 
States. These cases have usually been supposed to be instances of 
typhoid fever, from which, according to Dr. Guit^ras, they are to 
be separated by the suddenness of their onset, the temperature of 
the first day reaching 103^ F., or even higher ; by the course of 
the fever, which is extremely irregular, indefinite as to duration, 
and almost always has the morning remission more accentuated 
than in typhoid fever; by the absence of petechia, miliaria, rose- 
colored spots, tenderness, and gurgling in the iliac fossa ; by the 
tongue remaining moist, with only a light creamy coating, inter- 
rupted by a clear streak along the edges and median line; by 
the absence of cerebral symptoms, except at times when the fever 
rises very high ; and by the mental alertness instead of hebetude. 
Diarrhoea, although often absent, may be present, and even be 
severe and bloody. 

Many cases of obscure indisposition during intense hot weather, 
especially in children, are really mild instances of derangement 
of function of the body by heat, — that is, of thermic fever. 
Dr. C. Comegys, of Cincinnati, was the first to call attention to 



DISORDERS OF CONSCIOUSNESS. 383 

the fact that cases of cholera infantum^ so called, are frequently 
instances of thermic fever and yield at once to the use of the cold 
bath. It has long been known that in cholera infantum there 
is often a sudden increase in the fever, with or without lessen- 
ing in the number of the passages, but with a rapid loss of con- 
sciousnesS; which is likely to end in death. Under these circum- 
stances the cause of the cerebral symptoms is the elevation of the 
temperature. As it occurs in our large cities in hot weather, 
cholera infantum is frequently, if not usually, a form of thermic 
fever, and yields with great readiness to the systematic use of the 
cold bath. In all cases of this character the physician should use 
a thermometer, and if the temperature be found distinctly above 
the norm it should be reduced by systematic cold bathing. (See 
article on ^' Sunstroke,^^ Encydopcedia of Medicine^ vol. v., Phila- 
delphia, 1886.) 

Apoplexy. — The term apoplexy, as used in this work, applies 
to cases in which consciousness is suddenly lost as the result of dis- 
turbance in the circulation of the brain. Scientific accuracy would 
require that cases of arrest of the cerebral circulation should be sep- 
arated from cases of congestion or hemorrhage : the diagnosis, how- 
ever, between loss of consciousness which is the result of arrest 
of circulation in the brain by an embolus and the unconscious- 
ness which is due to a sudden rupture of a vessel and hemorrhage 
into the brain is frequently not possible. Moreover, it is by no 
means certain that even in hemorrhagic apoplexy the suspension 
of cerebral functions is the result of a congestion or of an excess 
of blood in the brain. For these reasons it seems to me wisest to 
consider under one heading all losses of consciousness connected 
with circulatory brain-disturbance, and afterwards to point out the 
few facts of value that we have as guides in separating between 
the forms. Again, it should be said that, except by the presence 
of paralysis or convulsions, we have no way of distinguishing 
between an apoplexy which is simply due to congestion of the 
brain and one which is connected with more or less permanent 
organic changes. It has been denied that there is such a thing as 
simple congestive apoplexy ; but there can be no doubt of its occur- 
rence. I have seen it developed without obvious cause, to be 
recovered from without sequelae, and never to recur in after-life. 
A congestive apoplexy may be due to a brain-tumor, or to a 



384 DIAGNOSTIC NEUROLOGY. 

syphilitic disease of the brain or its membranes. For a detailed 
discussion of these comas, see article on Organic Coma. 

For description and study^ cases of apoplexy may be arranged 
in two classes, to which the names of sthenic, or congestive, and 
asthenic, or syncopal, may be given. 

There are no etiological diiferences between these two classes. 
Extreme typical cases differ widely and characteristically in their 
symptoms, although they rest upon similar structural changes. 
Moreover, every possible intermediate variation occurs in nature 
between an extremely sthenic and a typically asthenic apoplexy, 
so that the two classes are not naturally separated from each other, 
but are artificially characterized for the purposes of discussion. 

The apoplectic attack may come on with great suddenness. It 
may, however, be preceded by prodromes, which are in some cases 
affirmed to have lasted for some hours. Sometimes without dis- 
tinct warning the patient drops unconscious, or he may become 
confused in speech and manner, and then suddenly be stricken, 
or else gradually grow more and more heavy and finally sink into 
unconsciousness. At the height of the attack the unconscious- 
ness is complete. The pupil is fixed, dilated or contracted, as 
the case may be. In the congestive form the face and conjunc- 
tivae are intensely suffused, dark purplish red. The breathing 
is loud, snoring, and stertorous. The pulse is usually full and 
bounding. It may be slower or more rapid than normal; oc- 
casionally it is small and hard. The surface is warm. 

In the syncopal form the face is pale, and the breathing quiet, 
or, if stertorous, not loud and harsh in its sound. The surface 
is coolish, and the pulse rapid and feeble. 

Paralysis, convulsions, and great rise of temperature may occur 
in either variety of apoplexy. They are proof of the presence 
of an organic lesion. The apoplexy may end in death, which is 
commonly developed by a more or less rapid increase of the symp- 
toms. The unconsciousness remains complete ; the pulse, whether 
originally strong or feeble, continually falls in force; the respira- 
tion grows more and more shallow, or more and more irregular, 
and may at last gradually die away or suffer sudden arrest. The 
cerebral reflexes are frequently lost early in a case of severe apo- 
plexy, especially when the basal region is invaded by the lesion. 
Thus it is that the power of swallowing is affected. Complete 



DISORDERS OF CONSCIOUSNESS. 385 

loss of this function is a very serious if not a fatal symptom. 
When recovery occurs it is usually gradual, although in rare cases 
the patient may arouse himself suddenly. Even when the patient 
seems rational, mental action may still be very imperfect. 

Unconsciousness from Indirect Causes. — Unconsciousness 
more or less closely resembling that of apoplexy occurs from a 
multitude of causes. Such unconsciousness is usually developed 
gradually, and is accompanied by other symptoms which at once 
distinguish it from the unconsciousness of apoplexy. With a clear 
history there is rarely any difficulty in distinguishing these vari- 
ous forms of unconsciousness from that due to disturbances of the 
cerebral circulation. Very frequently, however, in hospital prac- 
tice the physician is called upon to make immediately such diag- 
nosis as may be necessary for treatment without having knowledge 
of the antecedents of the attack. The importance and difficulties 
of such diagnosis seem to me to justify the consideration in this 
place of the more important forms of unconsciousness which are 
likely to be brought into a hospital. 

In the first place, the patient should always be carefully ex- 
amined for the evidences of traumatism, — cuts about the head, 
bruises, etc. I once saw at an autopsy upon a man who had 
been brought into the hospital unconscious, and in whose case 
there was no suspicion of traumatism, a knife-blade projecting 
two inches into the brain, and broken off close to the outside of 
the skull. A traumatism may be present without the physician 
being able to detect it, but usually some local indications of 
the injury will be revealed by close inspection. In the case 
just spoken of the wound was very narrow and small, and was 
entirely concealed by the bushy hair. 

Loss of consciousness may be caused by poisoning and by great 
emotional disturbance, or it may be an early symptom of acute 
blood-diseases. Unconsciousness from acute alcoholism is very 
frequent in large cities. Not very rarely persons supposed to be 
only dead-drunk are put into station-house cells, to be found dead 
some hours afterwards. Even when suspicion is aroused, the 
diagnosis between apoplexy and deep intoxication may be very 
difficult. The odor of alcohol about the breath or the person, 
and its presence in the urine, point towards alcoholic poisoning, 
but cerebral hemorrhage may occur after either moderate or im- 

25 



386 DIAGNOSTIC NEUROLOGY. 

moderate drinking. It is in such cases that mistakes are most 
liable to occur. Whenever by shaking, shouting in the ear, etc., 
a drunken person cannot be aroused, the probabilities of cerebral 
hemorrhage are strong enough to justify the temporary diagnosis 
and the institution of proper measures of relief. A very careful 
examination should be made for evidences of paralysis. Under 
the conjoint influence of alcohol and cerebral hemorrhage the 
universal muscular relaxation is so complete that the detection of 
a local palsy may be a matter of the greatest difficulty. Drawing 
of the face to one side is of course decisive, and if in breathing the 
air comes out with a sort of puff and pulling of one corner of the 
mouth, the case is one of cerebral hemorrhage. If the patient be 
at all restless, the motionlessness of the arm or leg of one side 
will usually betray a hemiplegia. If the pupils are unequal, the 
probabilities are in favor of cerebral hemorrhage. In any doubt- 
ful case the physician should be very careful not to affirm that 
the patient is suffering simply from drunkenness, but should 
reserve his opinion. 

0/)m??i-poisouing produces symptoms very similar to those of 
apoplexy, and I have seen cases in which the diagnosis was simply 
impossible. The presence of hemiplegic or monoplegic palsy is, 
of course, decisive. But I have seen inequality of the pupils pro- 
duced by opium. The remarks made in regard to distinguishing 
alcoholic unconsciousness apply with equal force to opium-poison- 
ing in its advanced stage. 

Urcemic poisoning is a very frequent cause of unconsciousness, 
and, unlike alcoholic and opium poisoning, is often associated 
with convulsions. The diagnosis between uraemic and organic 
convulsions has been already discussed. (See page 118.) It is 
sometimes impossible to make an immediate diagnosis between the 
quiet form of uraemia and cerebral hemorrhage, especially since 
in uraemia serous effusion into the cerebral ventricles is common. 
Cerebral hemorrhage itself is not rare in advanced kidney-disease. 
In every case brought into a hospital unconscious the urine 
should be at once examined. If it be normal in specific gravity 
and free from albumen, the probabilities are strongly against urae- 
mia. If the urine be scanty and of low specific gravity, much 
more if it be albuminous, the patient is probably suffering from 
kidney-disease. The presence of local palsy, even though there 



DISORDERS OF CONSCIOUSNESS. 387 

be advanced renal degeneration, is demonstrative of either hemor- 
rhagic or serous exudation into the brain. A temperature above 
the normal without convulsions would, according to the teaching 
of the French clinical school, prove that the patient is suffer- 
ing from something else than uraemia. I, however, doubt very 
much the correctness of this teaching. (See page 121.) Usually, 
but not always, the patient in simple uraemia can be aroused to 
some slight extent. 

A partial unconsciousness may result from various irritative 
poisons which do not commonly affect the cerebrum. I have seen a 
marked stupor amounting to almost complete unconsciousness the 
chief symptom of poisoning by Paris green, and there are numer- 
ous cases on record in which the ingestion of large doses of tartar 
emetic or other violent irritant has been followed by symptoms 
similar to those of my case. In some of these cases when no 
history is obtainable a correct diagnosis may be almost impos- 
sible : nevertheless a trifling circumstance, if the physician be suf- 
ficiently alert, may give the necessary clue. The circumstances of 
the case, the friends of the patient, and, if he be at all sensible, 
the patient himself, should be most carefully examined. 

A very important class of cases is those in which collapse with 
more or less complete unconsciousness occurs as an early symptom 
of severe internal disease, — either a local affection, such as a gas- 
tric or an intestinal perforation, the rupture of an aneurism, etc., 
or a general blood-disease. 

With a clear history the diagnosis may be very easy ; but often 
in practical life the history is misleading or altogether absent. 
The suspicion of the physician should be aroused by noticing that 
the loss of consciousness is not complete and is accompanied by 
evidences of cardiac failure, coolness of the skin, and a peculiar 
" decomposed'^ expression of the countenance seen only in mortal 
illness, and usually known as the Hippocratic countenance. It 
is impossible to describe exactly this facial expression, but to the 
experienced eye it is sufficient for the recognition of the gravity 
of the disease. In any case offering the symptoms just described, 
very careful examination should be made to detect the existence 
of a local lesion, and if evidence be found of a perforation or of 
any sufficiently severe local affection, the diagnosis becomes clear. 

When collapse, with more or less incomplete unconsciousness, is 



388 DIAGNOSTIC NEUROLOGY. 

an early symptom of a malignant systemic disease, we are forced 
to make the diagnosis by the process of exclusion. Usually it 
can be determined that the attack is due to some blood-disease, 
although often it is impossible to know the exact nature of such 
affection. Except in the case of a pernicious malarial paroxysm, 
an accurate diagnosis is not of great importance, because it has 
little bearing upon the treatment. It is, however, vital to recog- 
nize the true nature of a malignant chill. This can usually be 
done by excluding other causes of collapse and by paying atten- 
tion to the following positive indications : 

First The unconsciousness is partial : the patient can be aroused, 
and when aroused speaks in a feeble, usually whispering, voice. 

Secondly. There are evidences of internal congestions, such as 
almost complete absence of respiratory murmur, vomiting, gas- 
tric or abdominal tenderness, increased percussion-dulness over 
the liver or spleen, suppression of urine, etc. 

Thirdly, The temperature is disturbed : it may be distinctly 
lowered ; or in some cases there is a low external temperature 
with a high internal temperature. 

Fourthly. A history of previous malarial attacks or of exposure 
to malarial influences can be obtained, and the season of the year 
is usually that at which malarial fevers prevail. 

Fifthly, The patient is an adult, and does not present paralytic 
or other symptoms characteristic of cerebral hemorrhage. In chil- 
dren malignant malarial paroxysms do not occur, at least in this 
climate (that of Pennsylvania), whilst primary collapse from 
acute malignant constitutional affections, not malarial, is in adults 
excessively rare. 

In any doubtful case the patient should be given the benefit of 
the doubt, and when the collapse has been recovered from, fifty 
grains of the sulphate of quinine should be administered during 
the next twelve to eighteen hours. 

Collapse with more or less complete loss of consciousness may 
result from emotional excitement. Many years ago, during a chol- 
era epidemic, in answer to a sudden professional call, I found a 
man in collapse and partially unconscious, who, when aroused, 
said in a suppressed, whispering voice that he had had a sudden 
furious attack of vomiting and purging, which had ceased but had 
left him in his present condition. I supposed that the case was 



DISORDERS OF CONSCIOUSNESS. 389 

one of cholera ; but the sequel proved that shortly before I saw 
him the man had cut the tliroat of a prostitute after cohabitation 
with her and left her dead in her bed. The collapse I witnessed 
was caused by the emotional reaction which developed when the 
madness of his orgy had passed oflF suflSciently to allow him to 
recognize the results of his actions. 



SLEEP— ITS DISORDERS AND ACCIDENTS. 

In treating of sleep and its disorders I shall divide the subject 
into three parts : 

First. Abnormal wakefulness. 

Second. Abnormal somnolence. Morbid sleep. 

Third. Accidents or groups of symptoms which occur during 
sleep, and which are not elsewhere spoken of in this book. 

ABNORMAL WAKEFULNESS. 

In cases of simple insomnia the form of the sleeplessness 
varies. In some instances the subject is simply unable, when 
bedtime comes, to go to sleep. In other cases he goes to sleep 
readily, but in the course of two or three hours wakes, and is 
unable to slumber again. The latter form of insomnia, in my 
experience, is not commonly the precursor of severe mental affec- 
tion. This form of insomnia is, on the other hand, often obstinate. 

Insomnia may be prodromic of various diseases of the brain. 
It is very common in the insanities. It is also present not rarely 
in such general organic brain-diseases as general paralysis of the 
insane, but is seldom a symptom of tumor or other focal brain- 
lesion. It may be produced by various diseases of organs other 
than the cerebrum. It may exist, however, in its most aggravated 
form without other evidences of cerebral disturbance, and in some 
cases cerebral exhaustion, and even more severe mental symptoms, 
are without doubt produced by the loss of sleep. The diagnosis 
of the cause of an insomnia is to be made by exclusion. If other 
symptoms of cerebral disease are wanting, the condition of the 
heart and kidneys should be carefully examined, because latent 
disease of these organs occasionally has sleeplessness for its chief 
manifestation. When no disease of the brain or other portions 



390 DIAGNOSTIC NEUROLOGY. 

of the organism can be made out, the diagnosis of simple or 
functional insomnia must be settled upon. 

MORBID SLEEP. 

In studying the phenomena of disordered or abnormal sleep, I 
shall first consider those disarrangements of the function which 
occur in acute fevers or other diseases not directly connected with 
the brain. 

Disorders of Sleep connected with Acute Fevers. 

It does not seem necessary to occupy space in the present vol- 
ume with any elaborate description of the various derangements 
of sleep which occur in acute fevers. Such derangements may 
consist of morbid wakefulness, or of a peculiar wakefulness with 
delirium and partial unconsciousness, or of true stupor or coma. 
In some cases these manifestations depend upon high bodily 
temperature; they may also be produced by an excessively low 
bodily temperature. In other cases of fever the disturbances of 
sleep are probably the result of impaired brain-nutrition, due to 
the alteration of the blood. An improper aeration of the vital 
fluid, such as occurs in severe pneumonia, may for a time cause 
aggravated wakefulness, but more usually it manifests itself in 
stupor and coma. 

In some cases of fever the patient will awaken from a sleep of 
several hours' duration, and insist that he has never closed his eyes 
during the time, probably because his dreams have been so vivid 
that they have conveyed the feeling of wakefulness. To this 
state the name of coma-vigil was given by Chomel in 1834. In 
1849 the term was applied by Dr. Jenner to a condition entirely 
different from that just spoken of. In the coma-vigil of Dr. 
Jenner the patient lies with his eyes wide open, gazing into 
vacuity, his mouth partially opened, and his face pale and devoid 
of expression. The pulse is rapid and thready or imperceptible ; 
the movements of respiration can scarcely be made out; whilst 
the cold moist skin marks the presence of a deadly collapse. 
The patient is awake, but is absolutely indifferent to everything 
that is going on about him. In some cases this state is pre- 
ceded by somnolence. It is much more frequent in typhus than 
in typhoid fever, and, according to Murchison, in typhus fever 



DISORDERS OF CONSCIOUSNESS. 391 

it IS an invariably fatal symptom. I have seen it in typhoid 
fever in a single case followed by recovery. 

Nelavan. — Nelavan, or the so-called African sleeping disease 
{hypnosis of Drs. Daguaire and Nicolas), is an acute fever in 
which excessive somnolence is the most characteristic symptom, 
and is probably dependent upon the direct action of the poison in 
the blood upon the brain-cortex. First described in 1819 by Dr. 
Winterbottom, this affection has of recent years had numerous ex- 
positors. It is endemic on the west coast of Africa, but appears 
to occur epidemically in some of the West India islands. It at- 
tacks the negroes especially, but has in a number of instances 
decimated regiments of French troops. In most cases it comes on 
gradually, but it may begin brusquely. There is at first a slight 
frontal headache, with a sense of constriction in the forehead, 
attended by a mild fever. The vision may at this period be dis- 
ordered. The gait becomes irregular, and not very infrequently 
there is a distinct ataxia. Even during the first hours of the 
headache an intense desire for sleep is manifested. This con- 
tinually increases until the patient is overpowered by an irresist- 
ible somnolence. During the period of sleepiness the strength 
fails, the spirits are depressed, and there is some fever, but usually 
neither diarrhoea nor constipation develops, and the forces of the 
circulation are well maintained. The somnolence when once devel- 
oped continues to become more and more intense, and the patient 
gradually sinks into a profound coma, out of which he cannot be 
aroused. There is at this time complete loss of sensibility. The 
coma may pass quietly into death; but frequently there are more 
or less violent convulsions, and in some cases sloughing bed-sores 
mark the failure of nerve-power. There are no pathognomonic 
post-mortem lesions, but in 1873 Dr. Macarthy called attention 
to swelling of the glands in nelavan as characteristic. In this he 
is confirmed by Dr. Nicolas {Bev. Med. de la France et de VEtr an- 
ger, 1880). The disease is very fatal : out of one hundred and 
forty-eight cases seen by Gu6rin at Martinique but one recovered 
{Th^e, Paris, 1869, No. 201). 

Abnormal Sleep, 

The discussion of morbid somnolence is in the present state 
of our knowledge attended by much difficulty, as it seems impos- 



392 DIAGNOSTIC NEUROLOGY. 

sible to draw the lines between the different varieties of uncon- 
sciousness, and it is not always possible to give a clear explanation 
of the cause of the symptoms. In its simplest form the symp- 
tom consists of an excessive drowsiness, which causes the sub- 
ject to fall asleep at any time during the twenty-four hours, even 
when in the midst of work or conversation, and leads to his pass- 
ing many hours daily in bed. When the morbid tendency is 
a little stronger, the impulse to sleep becomes irresistible, and 
its influence is so continual that the waking periods may be re- 
duced to only a few hours out of a week. No distinction can 
be made between the sleep that occurs in many of these cases and 
that of normal slumber. The cases grade regularly from the 
person who is simply known as a profound sleeper, to the sub- 
ject who passes most of his time in unconsciousness. In lighter 
cases the patient can be awakened out of the sleep, but in the more 
severe forms of the disorder it is not possible to arouse the sleeper. 
Here also a regular series of cases exists between the sleep out of 
which the subject is easily aroused and that out of which he cannot 
be awakened at all. 

In the more prolonged cases of excessive sleep the patient 
remains in a condition of insensibility for weeks, months, or 
years. Dr. Gueneau de Mussy reported to the French Academy 
of Medicine the case of a woman who was said to have gone to 
sleep in 1808, and to have been still sleeping at the time of the 
report, January, 1838. During this time the woman remained im- 
movable upon her bed, with her limbs drawn up over her stomach. 
At first she took food, but soon she ceased to receive any nourish- 
ment except the sacrament, which was administered on the first 
Sunday of every month. As this case appears to rest solely upon 
the authority of a French cur6, and not to have been seen by the 
doctor himself, the account must be accepted with allowance. 
There are, however, similar instances in literature. Thus, a case 
is recorded in the New York 3Iedical Gazette, iv., 1853, in 
which a man slept five years; one in the Richmond Medkal 
Journal, 1867, in which a girl slept eighteen years; and the 
" sleeping girF^ of Turville is afl&rmed to have not awakened for 
ten years {Lancet, June, 1880). Dr. Gaulke (Vierteljahrsch. fur 
Gerichtliche Medicin, vol. xxvi., 1877) gives an account of a pris- 
oner who for two years had been in a death-like stupor. Dr. 



DISORDEES OF CONSCIOUSNESS. 393 

Blondet details the history of a young woman who slept twelve 
months. Although the correctness of some of these reports is open 
to doubt^ other cases might be cited^ and it cannot be gainsaid 
that the unconsciousness may last for years, either unbroken or 
interrupted by brief intervals of consciousness. 

Morbid somnolence of a mild type passes by insensible grada- 
tions into that condition known by some English authors as trance^ 
and usually spoken of by French writers as lethargy. Trance, 
or lethargy, may or may not be ushered in by marked hysterical 
symptoms, such as immoderate depression or excessive gayety, 
convulsions, hallucinations, etc. Usually in the course of a very 
short time the symptoms are fully developed, and the subject is 
in absolute repose. The face may be red and hot, especially in 
the first days of the attack, but usually it is pale. The pulse 
at first may be regular and slow, but after a long sleep it is rapid 
and feeble ; the respirations, generally quiet, may at times become 
hurried, irregular, and even stertorous. In severe cases the 
movements of the thorax may be so slight as to be traceable with 
diflBculty. The muscular system, often thoroughly relaxed, may 
be rigid, and in many cases muscular relaxation alternates with 
muscular contractions, or even contractures. The eyes are opened 
or closed ; very frequently minute tremors affect both the lids and 
the eyeballs. The jaws are often set, and sometimes an excess of 
saliva of even foam gathers about the mouth. In the profound- 
est cases tliere is complete anaesthesia of both the common and the 
special senses, so that neither pinching nor cutting, neither cold 
nor heat applied to the skin, elicits response. The pupils are 
usually dilated ; they often respond to a powerful light, which, 
however, calls forth no other signs of life. Sometimes the pa- 
tient can be readily fed by means of a spoon, but generally in 
severe cases it is necessary to use the oesophageal tube. Usually 
digestion is good, but the stools are at long intervals and scanty. 
The urine is in most cases scantily secreted, and is passed invol- 
untarily. Considering the small amount of nourishment taken, 
the bodily nutrition is often surprisingly maintained, but in 
prolonged cases there comes, sooner or later, great emaciation. 
The bodily temperature may in the earlier parts of the attack 
be somewhat elevated, but ordinarily it is distinctly subnormal. 
The awaking is usually, but not always, sudden. During the 



394 DIAGNOSTIC NEUROLOGY. 

course of such a lethargy the subject may pass into a condition 
which has been mistaken for death. The bodily temperature falls, 
the respiration becomes so passive that no movement of the tho- 
rax or abdomen is perceptible, and, unless a feather or other light 
object be held to the mouth, breathing may seem to have ceased. 
The beats of the heart diminish in frequency and in force, so 
that they become imperceptible even upon auscultation. The 
face takes on the waxy whiteness of a corpse. The muscular 
system is in complete resolution, the dilated pupil no longer reacts 
to light, and even the cornea is filmy as in a corpse. This death- 
like condition may last for only a few hours, or may continue from 
one to several days, after which, little by little, respiration is re- 
established, the pulse returns, and the circulation brings new life 
into the limbs: after such a crisis the subject may awake im- 
mediately, or may continue to sleep. 

A condition which is allied to that of hysterical lethargy or 
trance has long been known as catalepsy, a term to which, how- 
ever, so many meanings have been attached as to give rise to an 
almost hopeless confusion in literature. In its correct use it sig- 
nifies a form of morbid sleep which is characterized by loss of 
consciousness and of voluntary motion, and by a peculiar condi- 
tion of the muscles, so that the body or the limbs take without 
resistance any position in which they are placed, and preserve 
without apparent effort such position for an indefinite time. In 
some cases of insanity and in other neuroses the muscles pass 
into a state somewhat resembling that of catalepsy. These are 
not, however, instances of catalepsy, to which, in truth, the loss 
of consciousness is as necessary as is the peculiar condition of the 
muscles. To designate muscular symptoms resembling those of 
catalepsy occurring in other conditions the term cataleptoid may 
well be used. 

Catalepsy generally develops gradually, but it may come on 
abruptly as the result of a powerful emotion. As an instance 
of such sudden development may be cited the case recorded in 
1415 by Lafaille [Annales de Toulouse, 1st part, 1415) of two 
Gray friars who, during a sermon on the Passion, were struck 
immovable in the attitude of devotion. Usually the cataleptic 
status is preceded by lethargy, convulsions, or other pronounced 
hysterical symptoms. It lasts from two hours to a day, and may 



DISORDERS OF CONSCIOUSNESS. 395 

continually recur, so that the patient is said to be cataleptic for 
many days or even for weeks. The facial expression may be 
that of apathy ; in some cases it is that of devotion, of rage, or of 
whatever passion the subject was in at the time of the fixation 
of the muscles. The eyes are wide open, with quiet lids. The 
body is motionless, in the posture in which it has been placed 
or in which it has settled during the arrest of active motion. There 
is no power of voluntary movement, but the limbs are not rigid 
or contracted. When taken hold of, they bend with the plasticity 
of wax. In any position in which the body or limbs are placed 
they remain for a long time, and Berger (quoted by Barth) is 
said to have seen the most bizarre and difficult attitudes steadily 
maintained for seven consecutive hours by a young cataleptic 
woman who was constantly under observation. During the 
whole of the cataleptic state there is complete anaesthesia of both 
the common and the special senses, so that the most violent irri- 
tations of the skin produce no reaction. Respiration is regular, 
the pulse maintains its normal rhythm and rate, and the general 
bodily functions appear to go on unaffected. 

A condition resembling that of trance or catalepsy, in which 
consciousness is preserved, although the patient has no control 
over the voluntary movements, may develop as the result of a 
severe acute disease or from other cause. It is affirmed by Barth 
that in some cases which in other respects entirely resemble those 
of catalepsy the patient after coming out of the condition has 
recited all that occurred during the crisis. To those cases of leth- 
argy in which consciousness has been preserved the term lucid 
lethargy has been applied. If in a lucid lethargy the death- 
like condition spoken of on page 394 has developed, the patient 
may be thought to be dead. There can be little doubt that under 
these circumstances premature burial of a conscious person has 
occurred. In my childhood I well knew an old and esteemed 
minister of the Society of Friends who, in one of the epidemics 
of yellow fever, after an attack of the disease, passed into this 
condition and was prepared for burial. Although perfectly cog- 
nizant of his danger, he could give no sign, until by a supreme 
effort he succeeded in making some slight movement of the eye- 
lids, which indicated life. 

If in insanity a cataleptoid condition appears, the true character 



396 DIAGNOSTIC NEUROLOGY. 

of the apparent catalepsy can usually be determined by noticing 
that the body and limbs when placed in bizarre positions show 
tremors or other evidences of fatigue. In catalepsy the limb 
when it falls falls like a w^ax arm which has been bent and slowly 
straightens by its own weight. 

According to my thinking, it is not at present possible to ar- 
range the various cases of morbid somnolence into symptomatic 
groups which can be distinguished from one another by the symp- 
toms. In a previous chapter choreic movements were shown to 
be due to a peculiar condition of the ganglionic nerve-cells, capa- 
ble of being produced by various causes. It seems to me that it 
must also be considered that the condition of morbid sleep is due 
to an altered nutrition of nerve-cells connected with conscious 
life, which altered condition cannot always be recognized by the 
microscope, and may be produced by various causes. The parallel 
between morbid somnolence and chorea is further evinced by the 
fact that the best classification that we can make of it is etio- 
logical. It will at once strike the reader that most of the groups 
which are separated in the following scheme are represented in 
chorea : 

Group first, those cases in which the unconsciousness is due to a 
distant reflex irritation. 

Group second, those cases in which it is an outcome of a pecu- 
liar nervous condition of unknown nature, to which the name of 
narcolepsy is applied. 

Group third, those cases in which it is hysterical. 

Group fourth, those cases in which it is connected with insanity. 

Group fifth, those cases in which it is due to an organic disease 
of the brain. 

Before taking up the consideration of these etiological groups, 
it is necessary to call attention to the fact that epileptic attacks 
may closely simulate morbid sleep. 

Epileptic Sleep, — A sleep of some hours' duration out of which 
the patient cannot readily be awakened is a portion of a typical 
epileptic attack. In rare cases the whole epileptic paroxysm may 
be comprised in a sleep which may be prolonged for several days. 
The following case, reported by Surgeon M. Chabert {Receuil de 
M^moires de Medecine et de Chirurgie militaires, 1867, vol. xviii. 



DISORDERS OF CONSCIOUSNESS. 397 

p. 16), was probably epileptic. A soldier, twenty-six years of age, 
suddenly disappeared, and was marked as a deserter. Eighteen 
days later he was found deeply buried in a pile of straw lying in 
an out-house, the door of which is asserted to have been locked for 
seven days. The man was completely unconscious and apparently 
dead. The face was deadly pale, with dilated pupils, the limbs 
were relaxed, the surface was cold and without sensibility, the 
respirations were completely suspended, and even on auscultation 
no evidence of cardiac action could be made out. After half 
an hour^s work with frictions, external heat, etc., an inspiration 
was taken : in a short time respiration and circulation were re- 
established, and on the next day the man was conscious. Inquiry 
showed that at the age of twelve years the patient had been seized 
with a furious migraine, had disappeared, and was found twenty- 
four hours afterwards asleep in a granary. Two months later he 
had a second similar attack. In the twelve or fourteen years 
after this he had seven or eight attacks, during which he would 
be deprived of consciousness for several days. 

Another case, which may have been hysterical, but possibly 
was epileptic, is that recorded by Dr. Marduel. The soldier was 
admitted to the Military Hospital of Lyons on the 21st of March, 
1870, profoundly unconscious and insensible, but with a full reg- 
ular pulse of eighty-four, and calm respiration. In spite of the 
use of cold affusions and violent electrical currents, the sleep con- 
tinued for seventy-four hours. Subsequently the patient had 
another attack of sleeping, during which there was a violent con- 
vulsion. The fact that in one of these sleeping periods there was 
general hypersesthesia of such character that touching of the skin 
would immediately produce a violent tetanus or opisthotonos, 
points towards hysteria. 

Refiex Unconsciousness. — It is well known that in poisoning 
by gastro-intestinal irritants stupor or insensibility may be so 
pronounced as to mask the ordinary symptoms. I have seen this 
in a case of poisoning with Paris green. I was once called to a 
child who was in profound insensibility, with very alarming col- 
lapse, apparently without cause, but who, I shortly learned, had 
eaten stale cream puffs a few hours before. By the use of a hot 
bath and emetics consciousness was soon restored. The following 
cases may be cited as instances of reflex unconsciousness. 



398 DIAGNOSTIC NEUROLOGY. 

In the Boston Medical and Surgical Journal, 1853, xlix. 363, 
is reported the case of a patient who, as the result of the inges- 
tion of indigestible food, passed into a semi-comatose condition, in 
which he remained for two weeks and then died. At the autopsy 
the lesions found were severe inflammation of the small intestines 
and tubercular degeneration of the abdominal glands. A more 
satisfactory case is reported by Dr. Katerbau {Magazin fur Ge- 
sammte Heilkunde, Berlin, 1825, p. 157); a seventeen-year-old 
Jewess, who had slept for four days and nights, under the influence 
of medicine passed a knot containing twenty-four round worms, 
and immediately awoke. 

That the reflex sleep may take the form of catalepsy is shown 
by a case reported by Dr. Mayer {Ann. de la Soc. Med. d^AnverSy 
May, 1863), in which a boy, nine years old, for five or six con- 
secutive days had a diurnal attack of catalepsy lasting several 
hours, and was at once cured by the expulsion of a large number 
of intestinal worms. 

Narcolepsy. — The cases of morbid sleep which are here grouped 
together under the name of narcolepsy vary in the intensity of 
their symptoms from drowsiness to a sleep which ends in death. 
It is most probable that the cause of the sleep varies, and that 
several distinct affections are represented in the group. The best, 
however, that can be done at present is to separate the cases into 
three sub-groups, which are not very clearly distinguishable and 
indeed are probably closely connected by intermediate cases. In 
the first of these groups the subject passes many hours in what 
seems to be ordinary slumber. In some cases the sleep comes on 
daily, in others at longer intervals. In some instances there is a 
perpetual drowsiness, in others the patient when awake is not 
sleepy. As illustrating these various facts I cite the following 
cases.* 

Dr. J. W. Gloninger reports in the American Medical Record, 
vol. v., 1822, a case in which a man gradually passed into a con- 
dition in which he was excessively drowsy all the time, perpetu- 
ally falling asleep when at work, and habitually spending eigh- 
teen hours out of every twenty-four in profound slumber. Dr. 



* For a large collection of cases of morbid sleep, see paper by Dr. Dana, 
Journal of X^ervous and Mental Diseases, April, 1884. 



DISORDERS OF CONSCIOUSNESS. 399 

Hanfield Jones [Lancet, January, 1870) details the history of a 
porter who was never free from drowsiness, falling asleep at all 
times, and habitually spending fourteen hours of the tw^enty-four 
in sleep. Dr. T. Brady (3Iedical Observations and Inquiries, 
London, 1867) records the case of a woman who for many years 
had slept eighteen hours a day, except four months in one year, 
during which she was like other people, and twenty-one days in 
another year, when she had a tertian fever and slept not more 
than two hours at a time. This woman could not be aroused out 
of her sleep. G. Ballet reports {Revue de 3I6decine, ii., 1882) the 
case of a wine-merchant who, when three years old, had an at- 
tack of lethargy lasting seventeen days after typhoid fever, and at 
the age of twenty-six began to suffer from excessive drowsiness, 
which caused him to fall asleep in all sorts of places and at all 
times, although his nightly sleep was very long and profound. 
Dr. Rudolph (New Orleans Medical and Surgical Journal, 1883, 
xi.) tells of a young ranchero who, after having been troubled by 
excessive somnolence during the day, had spells of sleep lasting 
from twenty-four to forty-eight hours. 

The second class of cases comprises those in which the parox- 
ysms of sleep come on at irregular intervals and continue for days. 
As an instance of this form of narcolepsy I cite a case reported 
by Dr. Outrepont {Neue Zeitschrift fUr Geburtskunde, 1844). A 
Jewess shortly after her marriage fell into a prolonged sleep, which 
had ever afterwards recurred periodically. The average length 
of the sleeping period was five and a half days, the longest time 
that she had ever slept being seven days. The intervals of wake- 
fulness lasted from two to twenty days, during which time she 
did not sleep at all, or had only a very little restless slumber. 
The sleep would come on suddenly, sometimes in the night 
and sometimes in the middle of the day. At the end of the first 
twenty-four hours she would awake with a very dry mouth and 
put out her tongue as though she wanted a drink, when an at- 
tendant would give her fluid nourishment, after which she would 
immediately go to sleep again. She appeared to have no con- 
sciousness of this brief awaking. She could not be aroused, but 
would awake spontaneously and suddenly in a very weak con- 
dition. The pulse during the sleep was about sixty-six, regular; 
the respirations were so feeble that the movements could scarcely 



400 DIAGNOSTIC NEUROLOGY. 

be observed, and the temperature was normal. Neither the urine 
nor the faeces were passed during sleep. The pupils were normal, 
but did not respond to light. Dr. W. G. Gimson (British Med- 
ical Journal, 1863, i. 616) reports a case in which a man after 
a severe cold had attacks of profound sleep. The sleep would last 
from twelve to twenty-four hours; the respirations were eighteen, 
quiet, the pulse sixty-four, regular, feeble ; skin warm, hands and 
feet cold ; he could not be awakened, and waked suddenly at last. 
At the time he was seen by the doctor the man passed forty out 
of forty-eight hours in sleep; once he slept eighty-four hours. 
He never took food nor had a passage from the bladder or the 
rectum during sleep. When awake the mental action was as 
good as ever. 

A third class of cases is that in which the sleep comes on with- 
out apparent cause, and becomes more and more profound until 
the patient dies. Thus, in a case reported by Dr. S. Weir Mit- 
chell to the College of Physicians, a woman suddenly became 
giddy and fell insensible; from this condition she soon aroused, 
but three days later she passed into a condition of sleep, during 
which she could be momentarily aroused and would answer simple 
questions. For eleven days she remained in this state, with some 
convulsive movements, and then died quietly. Careful post-mor- 
tem examination, with a microscopic study of the brain, failed 
to detect any cause of death. Some of the cases of the present 
group are probably instances of intense cerebral congestion, and 
might be relieved by venesection. Thus, Dr. Charles S. Spilman 
reports in the Transylvania Medical Journal the history of a boy, 
fifteen years of age, who, after the death of his father, fell into 
a condition of profound sleep, with occasional slight convulsive 
movements and a slow, laboring pulse. He could not be aroused; 
but after seventy-two hours of sleep forty-four ounces of blood 
were taken, and the boy at once awakened. In some fatal cases 
of apparent narcolepsy distinct lesions after death have been 
found. Thus, Dr. Haine reports [Gazette des Hdpitaux, vol. xlii., 
1869) the case of a girl, nineteen years of age, who died after a 
profound sleep which had come on suddenly and continued for 
fifty-six days. At the autopsy a small and very circumscribed 
spot of softening was found in the cerebrum. 



DISORDERS OF CONSCIOUSNESS. 401 

Hysterical Sleep. 

The most common variety of morbid sleep is that which is 
connected with hysteria. The symptoms usually take the form 
of lethargy or trance, with or without catalepsy. True narco- 
lepsy may, however, be closely simulated, the patient being con- 
tinually drowsy, and falling asleep at all times, but passing only 
the nights in profound slumber. The presence of other hysterical 
symptoms commonly betrays the nature of the somnolence. As 
illustrating the manner in which the various symptoms of hysteria 
are usually intermingled, I cite the following case reported by W. 
T. Gairdner {Brit Med. Journ,, October 30, 1875), in which a 
girl, after hysterical fits and hysterical chorea, suddenly became 
unconscious, with wide-open eyes and dilated pupils, at the same 
time speaking and singing incoherently, apparently as the result 
of hallucinations and delusions. This continued for about two 
weeks. A month or two later she fell into a deep sleep, which 
lasted eight days with an interruption of a few moments. During 
this sleep she could not be aroused, and had no passage from the 
bowels or the bladder. Some months later she had a second eight- 
day sleep : after awaking from this she passed into a condition in 
which she slept persistently, unless aroused, when she would get 
up and dress herself, but would remain awake only so long as she 
was in active exertion. 

A case of hysterical lethargy which shows the close relation 
between it and insanity is recorded by Dr. F. R. Mueller {Journal 
der Praktische Heilkunde, 1829, vol. Ixviii.). A young woman who 
had had slight melancholia was suddenly seized, whilst at church, 
with intense sleepiness, sat down on the door-step, went to sleep, 
was after a time carried home, and slept, with very brief inter- 
ruptions, for four years, three months, and sixteen days. Once 
during this period she was awake eighteen days, sleeping natu- 
rally at night, and seeming like herself. Her uninterrupted sleeps 
lasted from forty-eight hours to a week ; her waking periods were 
at first only ten or fifteen minutes, but afterwards several hours. 
During the sleep she would lie quietly upon her back, never 
altering her position, with her hands folded over her abdomen. 
The skin was parchment-like and dry; the eyelids were closed, 
with the eyeballs, when exposed, divergent; the face was deadly 

26 



402 DIAGNOSTIC NEUROLOGY. 

pale, except the lips, which were red ; the pulse was slow and 
regular, the breathing slow and very light; the insensibility of 
the skin was complete. She was much emaciated, and the tem- 
perature seems to have been subnormal. There was habitual stiff- 
ness of the muscles, which, however, could be readily overcome, 
and in the earlier months of sleep she had at times distinct cata- 
leptic symptoms. Often her somnolence went off gradually. 

The relation of hysterical sleep to the condition known as 
hypnotism is so close that it seems to me proper at this place 
to consider briefly the subject of hypnotism. To discuss all the 
phenomena of the state would require much more space than is 
permissible.* 

Hypnotism, — By causing a susceptible person to fix his eyes 
steadily upon a bright object, as a button, or by pressing the 
eyelids upon the eyes, or by other suitable i)rocedure, the con- 
dition of hypnotism is produced. In its most typical form it 
is composed of three stages: first, catalepsy; second, lethargy; 
third, artificial somnambulism. 

In catalepsy the subject appears as though petrified in his posi- 
tion. The eyes are fixed widely open, with dilated pupils and an 
insensible cornea. With rare exceptions, the general surface of 
the body is insensible to pain, but the special senses retain their 
activity. The extremities are supple, but when bent maintain for 
a great length of time any position into which they may have 
been placed. In this state (and still more markedly in the con- 
dition of lethargy) paradoxical contractures may be produced. 
They are developed by so flexing or bending a part as to throw 
the muscle into sudden and complete relaxation, when it imme- 
diately passes into a condition of severe tonic spasm. The con- 
tractures may also be developed by striking the tendons, or even 
by rubbing the belly of the muscle. A peculiar phenomenon 
which occurs during the catalepsy is that if the body or limbs are 
put into a position expressing some emotion, the face takas upon 
it an expression corresponding to this emotion, and the whole 
individual seems overwhelmed by emotional excitement. Thus, 
if the arms are thrust forward and the hands raised as though 



•^For details the reader is referred to the work of Ferdinand Bottey, 
Magnetisme animaley Paris, 1886, as an excellent treatise upon the subject. 



DISORDERS OF CONSCIOUSNESS. 403 

pushing away or shoving something out of sight, horror and 
fear gather upon the countenance, and the whole body seems 
to be recoiling from some dread object ; if the person be placed 
in the attitude of prayer, the expression will become one of in- 
tense devotion; if the posture be that of combat, rage will be 
developed. 

During the lethargic state there is complete relaxation of the 
whole muscular system : the head falls upon the shoulders, and 
the limbs are absolutely flaccid, and when raised drop as though 
dead. The eyes are closed, and frequently both the lids and the 
balls tremble constantly. The skin is insensible, so that pinching, 
sticking with needles, or other irritation provokes no response. 

The somnambulistic condition occurs in two forms, — one with 
the eyes closed and the other with the eyes open. The appearance 
of the person who is in somnambulism with closed eyes is pre- 
cisely what it has been during the state of lethargy, but now 
on the word of command the somnambulist rises, marches, and 
does whatever he is commanded. The insensibility of the skin 
remains, but the special senses are awake, and even much more 
acute than normal, so that the subject will be able to read in a 
darkened room, to hear sounds inaudible to others, or to recognize 
odors not perceptible by others. There is also in some cases ex- 
altation of the intellectual faculty. Thus, a young man, a student 
of mathematics, during an hypnotic state, solved with elegance 
and rapidity problems in trigonometry which during his natural 
condition he had essayed in vain. There is also a revival of the 
memory of facts apparently long since forgotten, and even an ex- 
pression of remembrances hitherto unknown to the consciousness 
of the individual when awake. 

The phenomena of somnambulism with open eyes diflPer from 
those of somnambulism with closed eyes in that instead of the 
subject being absolutely automatic he is full of an unconscious 
activity, and when left to himself moves restlessly hither and 
thither; at times he offers considerable resistance to the will and 
commands of the experimenter. The eyes are wide open, with 
the sight fixed, as in catalepsy, upon vacuity, or there may be a 
wild expression. Spontaneous hallucinations appear frequently 
to rise within the brain of the somnambulist and to find expres- 
sion in both word and deed. 



404 DIAGNOSTIC NEUROLOGY. 

Sleep in Insanity. 

Although true stupor may follow upon or be connected with 
pronounced evidences of mental aberration, yet in a large pro- 
portion of cases it is apparent rather than real. If an insane 
patient lie in bed absolutely still and inert, with closed eyes, 
giving no response to the loudest questioning and making only a 
feeble and slow resistance to personal violence, — or if, with head 
bent forward, joints flexed, and face frozen into an immobile 
apathy, he sit motionless in his chair, — he seems to be lost in un- 
consciousness, but none the less may he have knowledge of his sur- 
roundings and of his sorrows. This lethargy may be the direct 
result of an intense emotion or of delusion, and not be consciously 
assumed, but not rarely it is put on for a definite end, and main- 
tained with a tenacity of purpose which defies detection even 
during the intoxication caused by ether or by alcohol. In a ma- 
jority of cases, however, an assumed stupor can be detected by the 
use of intoxicants. In many cases it is impossible to penetrate the 
veil and to determine why the insane person keeps up for months 
an absolute silence and passivity; but the occasional revelations 
made by patients after they recover their reason show that a delu- 
sion may act very directly. A man believes that he has received 
commands from the Almighty to do as he does, and battles for his 
eternal salvation ; or he conceives that his attendants are con- 
spiring against him, and will do him great evil if once they are 
assured he is alive. In some cases the lethargy is the result of an 
overwhelming emotion produced by the delusion. The man about 
to be devoured by foul beasts or by the flames of hell is dumb 
through fear, or, as the German alienists say, is thunderstruck. 
Occasionally the insane sleeper is convinced that he is dead, and 
by this delusion his will is so far paralyzed that it is unable to 
act, and the man really cannot move, although the lower nervo- 
muscular apparatus is intact. 

Toxsemic Sleep. — The only forms of toxsemic sleep which 
require discussion are those which arise in chronic Bright's dis- 
ease and in diabetes mellitus. The symptoms of uraemia have 
already been sufficiently discussed, and it only remains to con- 
sider diabetic coma. 

Coma occurs during the course of diabetes in several forms. 



DISORDEES OF CONSCIOUSNESS. 405 

It may come on late in the disease as the result of secondary or- 
ganic alterations in the brain itself. In another class suddenly 
the strength gives out^ the pulse becomes very rapid and weak, 
the extremities grow cold, and in a very few minutes or hours the 
patient sinks into a syncopal stupor, which ends in death. The 
cause of these symptoms is sudden failure of a heart whose mus- 
cle has degenerated. Neither of these two classes of cases are 
entitled to be called diabetic coma. True diabetic coma may 
occur at any time or stage of the disorder. It is usually pre- 
ceded by a train of nervous symptoms, w^hich, with the coma, are 
now believed to be due to the presence in the blood of a sub- 
stance produced by the decomposition of the sugar. This sub- 
stance is supposed by some authorities to be aceto-acetic acid, and 
seems to be at least an acetone-producing principle. For this 
reason the name of acetoncemia has been given to diabetic coma. 
The peculiar odor of acetone can in most cases be detected in the 
breath, the urine, and the perspiration, whilst usually there is 
sufficient acetone in the urine to strike a Burgundy-red color 
with a solution of chloride of iron. 

According to Prof. Frerichs ( Uebei^ den Diabetes, Berlin, 1884), 
there are two distinct forms of diabetic coma. In the one variety, 
after great weakness, gastric disturbance, vomiting, diarrhoea, and 
perhaps some local inflammation, as a carbuncle or a bronchitis, 
there develop headache, restlessness, delirium, excessive anxiety, 
dyspnoea, with very deep expirations and inspirations, and with 
or without evident cyanosis, fall of temperature, great rapidity 
and feebleness of the pulse, somnolence, and finally coma, which 
ends in the majority of cases in death after from one to three 
days. In the other form of diabetic coma, whilst the patient is 
apparently in good bodily condition and has no dyspnoea, head- 
ache, staggering gait, and somnolence suddenly come on and end 
in a coma, which invariably proves fatal in a short time. 

OEGANIC STUPOR AND COMA. 
Organic diseases of the brain of which stupor or coma is a promi- 
nent symptom can best be studied for the purpose of diagnosis by 
dividing them into those which are accompanied by marked head- 
ache and those in which headache is wanting. These groups I 
shall respectively note as Group First and Group Second. 



406 DIAGNOSTIC NEUROLOGY. 

Group First. Organic brain-diseases in which headache and 
stupor are prominent symptoms are naturally divided into two 
sets, specific and non-specific. 

Non-^pecifiG Stuporous Affections. 

Brain-Tumor. — Stupor is liable to develop at any time during 
the course of a brain-tumor, although it is in no sense a charac- 
teristic symptom of such affection. In the last stages of brain- 
tumor, when the surrounding cerebral substance is undergoing 
softening, or when by pressure or progressive disease the impor- 
tant vessels are interfered with, stupor or profound coma is very 
common. The recognition of such a coma must depend upon the 
previous study of the case. Of different import is the stupor 
which occasionally develops from time to time in the earlier stages 
of the brain-tumor, and is not dependent upon severe structural 
lesions of other portions of the brain than those immediately 
implicated by the growth, but to a geneml cerebral congestion. 
Such stupor may or may not be accompanied by convulsions. 
It frequently comes on rapidly, and may in the course of a few 
hours pass off, or may remain several days and then subside. I 
have seen a patient with a gliomatous tumor who had been for 
several days absolutely comatose, passing the discharges involun- 
tarily, and thought to be dying, a few hours later walk to the 
clinic-room in a distant portion of the hospital. 

Meningitis. — A second cause of organic stupor and coma is 
inflammation of the meninges. Acute meningitis habitually ends 
in coma, and any time during the course of a chronic meningitis 
the symptom may be developed. The significance of coma occur- 
ring during an acute or even a chronic meningitis can scarcely be 
jnistaken. The detailed discussion of the symptoms of acute and 
chronic meningitis will be entered upon in the next chapter. 

Pachymening'itis Hsemorrhagica. — Pachymeningitis haemor- 
rhagica is a disease in which there is chronic inflammation of 
the dura mater, with the formation of a bloody growth or tumor, 
due to or connected with repeated hemorrhages into the part. It 
is essentially an affection of old age, or of persons who, from 
syphilis, scorbutus, or other constitutional dyscrasia, have degen- 
eration of the vessels. It also occurs as a secondary affection in de- 
mentia paralytica, brain-atrophy, hydrocephalus, etc. The head- 



DISORDERS OF CONSCIOUSNESS. 407 

ache is usually severe and throbbing, in most cases is not accurately 
localized, and often occurs in furious paroxysms, especially at the 
time ^vhen fresh hemorrhages take place. The motor disturbance 
may show itself in paresis, or in localized muscular movements, or 
in general epileptic convulsions. A shifting hemiplegia, which is 
now on the one side and now on the other, is not uncommon. Mus- 
cular twitching with subsequent rigidity may accompany or follow 
the shifting palsy, and permanent hemiplegia with contractions 
may develop. Conjugated deviation of the eyeballs is not infre- 
quent, but, as the hsematoma is almost invariably on the vault 
of the cranium, the ocular and other basal nerves are rarely, if 
ever, involved. If facial palsy happen, it will take the form that 
is characteristic of central brain-disorder. Psychical disturbance 
is very common, and vertigo is frequent. The pupils may be con- 
tracted and insensible to light, but when the cerebral compression 
is marked they dilate. During conditions of cerebral compression 
the pulse may be slow, but the pulse- rate varies almost indefinitely 
throughout the disorder. Drowsiness with an habitual excess of 
sleep is rarely wanting in cases which do not run a very rapid 
course. The stupor may be prolonged, but more frequently it 
comes and goes as the cerebral congestion varies. Profound coma 
is usually developed when pressure occurs from renewed hemor- 
rhages, and in the later stages of the disease when the cerebral sub- 
stance is undergoing alterations in the neighborhood of the lesion. 
In a large proportion of cases pachymeningitis is not recog- 
nized during life, and the diagnosis may be impossible. If the 
patient die in an early hemorrhage the symptoms will be simply 
those of apoplexy preceded by a more or less pronounced head- 
ache. In prolonged cases with characteristic symptoms the nature 
of the affection should be made out. The symptoms may resemble 
very closely those of tubercular meningitis, which is, however, 
an affection of children : if the patient be past middle life and be 
free from tubercular disease in other portions of the body, the 
diagnosis of pachymeningitis hsemorrhagica would be justified, — a 
diagnosis w^hich would be greatly strengthened by finding degen- 
eration of the vessels in other portions of the body. Choked 
disk, in one or both eyes, is frequent, and the coma in pachy- 
meningitis occasionally has remissions and exacerbations closely 
resembling those which sometimes occur in brain-tumor. The 



408 DIAGNOSTIC NEUROLOGY. 

affection is therefore liable to be confounded with brain-tumor; 
but the age of the patient and the peculiar drowsiness which 
occurs between the comatose conditions usually render the diag- 
nosis possible. Fiirstner has called attention to the temperature 
of the body as a means of diagnosing between pachymeningitis 
hsemorrhagica and a cerebral apoplexy. He believes that in 
the meningeal hemorrhage rise of temperature is not preceded 
by a fall, whilst in intra-cerebral hemorrhage such fall usually, 
although not invariably, occurs. (Archiv fur Psychiatric und 
NervenkrankheiteUj 1878, Bd. viii. pp. 1-31.) 

Specific Stuporous Afections. 

Syphilitic Coma. — The ordinary lesions produced by cerebral 
syphilis are meningitis, localized or diffused, and degeneration of 
the cerebral vessels. Either of these changes may give rise to 
somnolence or to profound coma. Such coma does not, how- 
ever, in its symptoms conform to a regular type, as described by 
Dr. Julius Althaus {3fedical News, vol. xlix. p. 428), but varies 
greatly in its manifestations. In the wards of the Philadelphia 
and University Hospitals the affection is so frequent that, al- 
though at least sixty per cent, of the cases recover, I have seen 
three die in one week ; and studies made chiefly in those hospitals 
lead me to divide syphilitic coma for the purpose of discussion 
into several varieties. 

The first and least common form may be known us coma fou- 
droyanty or fulminating coma. The symptoms in such cases may 
appear to develop suddenly in the midst of good health, but I 
believe that close examination will show that headache, vertigo, or 
some other indication of organic brain-lesion has always preceded 
the violent attack. I do not believe that acute syphilitic menin- 
gitis or an acute coma develops as a primary lesion or as a pri- 
mary symptom : both the lesion and the symptom are preceded by 
the formation of the gummatous tumor, or by pronounced degen- 
eration of the vessels. It is certain, however, that the structural 
disease may be essentially latent, and the attack appear to come on 
abruptly in the midst of health. An acute fulminating syphilitic 
coma might theoretically depend upon the obliteration of the 
cerebral vessels by embolus or thrombus. In such case the symp- 
toms would be those of embolism or thrombosis from other than 



DISORDEES OF CX)NSCIOUSNESS. 409 

specific causes. The alterations in the cerebral vessels produced 
by syphilis are slowly progressive, and^ although they not rarely 
end in cerebral softening with its accompanying stupor and coma, 
the symptoms in all the cases which I have seen have developed 
slowly ; the blood-current seems to be gradually shut off. Pou- 
droyant or fulminating syphilitic coma is an outcome of a gum- 
matous inflammation or growth. 

The stupor may or may not be accompanied by delirium or by 
convulsions. A man about thirty years of age, whom I saw in 
consultation, thought himself in perfect health, but became very 
drowsy about the middle of an afternoon, and, going to the back 
of his store, fell asleep. Being found in this condition, he was 
aroused, and with assistance got up-stairs to bed. Very shortly 
afterwards he became comatose, with delirious outcries and furious 
convulsions. In a case reported by Dr. J. A. Ormerod, a man who 
had been in good health, with the exception of headache, awoke 
one morning in a semi-delirious condition, and for three days slept 
steadily, arousing only for meals : after this there was impairment 
of memory and of the other mental faculties, but there were no 
more marked symptoms. 

In the cases reported by Dr. Althaus the coma developed rap- 
idly and quietly, and in several instances during sleep, so that, al- 
though local or general convulsive symptoms may be pronounced 
in fulminating syphilitic coma, the patient may be completely quiet 
and relaxed. Under these circumstances the symptoms are simply 
those of profound coma. There is nothing in the coma itself 
which will enable us to distinguished its specific source. Hemi- 
plegia or evidences of local palsy are usually wanting, but I 
have no doubt that it is possible for them to be present: in 
the case which I have just mentioned, after recovery of con- 
sciousness partial hemiplegia was very noticeable. The condition 
of the pulse varies, as it does in coma from other causes. The 
rate may fall far below normal, or the pulse may become rapid 
and fitful, or it may be hard and wiry : it may be large with 
high tension, or it may be large and soft. The cause of the 
coma is, I believe, congestion of the brain, entirely parallel to 
that which occurs in cases of non-specific cerebral gro^vths. The 
recognition of the fact that the symptoms are not peculiar, and 
are due to a secondary congestion of the brain, is very important. 



410 DIAGNOSTIC NEUROLOGY. 

because it leads to the practical conclusion that the first treatment 
of such a case must be precisely that which would be used for the 
relief of similar symptoms due to non-specific brain-lesions. In 
some cases life has been saved only by free venesection. After 
the acute symptoms have been subdued, very active specific treat- 
ment should be instituted. 

The second variety of syphilitic coma develops gradually. The 
patient sits all day long or lies in bed in a state of serai-stupor, 
indifferent to everything, but capable of being aroused, answering 
questions slowly, imperfectly, and without complaint, but in an 
instant dropping oflF again into his quietude. In other cases the 
sufferer may still be able to work, but often falls asleep while at 
his tasks, and especially towards evening has an irresistible desire 
to slumber, which leads him to pass, it may be, half of his time 
in sleep. This state of partial sleep may precede that of the 
more continuous stupor, or may pass off when an attack of hemi- 
plegia seems to divert the symptoms. The mental phenomena in 
the more severe cases of somnolency are peculiar. The patient 
can be aroused, — indeed, in many instances he exists in a state of 
torpor rather than of sleep; when stirred up he thinks with ex- 
treme slowness, and may appear to have a form of aphasia ; yet 
at intervals he may be endowed with a peculiar automatic activity, 
especially at night. Getting out of bed ; wandering aimlessly 
and seemingly without knowledge of where he is, and unable to 
find his own bed ; passing his excretions in a corner of the room 
or in other similar place, not because he is unable to control his 
bladder and bowels, but because he believes that he is in a proper 
place for such acts, — he seems a restless nocturnal automaton 
rather than a man. Apathy and indifference are the charac- 
teristics of the somnolent state; yet the patient will sometimes 
show excessive irritability when aroused, and will at other periods 
complain bitterly of pain in his head, or will groan as though 
suffering severely in the midst of his stupor, — at a time, too, when 
he is not able to recognize the seat of the pain. I have seen a 
man with a vacant, apathetic face, almost complete aphasia, per- 
sistent heaviness and stupor, arouse himself when the stir in the 
ward told him that the attending physician was present, and come 
forward in a dazed, highly pathetic manner, by signs and broken 
utterances begging for something to relieve his head. Heubner 



DISORDERS OF CONSCIOUSNESS. 411 

speaks of cases in which the irritability was such that the patient 
fought vigorously when aroused : this I have not seen. 

After some days of excessive somnolence and progressive deep- 
ening of the stupor, or sometimes more rapidly, the victim of 
cerebral syphilis may pass into a condition of profound coma, 
out of which he cannot be aroused, and during which his fseces 
and urine are either not passed at all or are voided involuntarily. 
This condition of coma may end in death ; but even when the 
symptom seems most serious the patient may gradually recover, 
slowly emerging from coma into stupor, and from stupor into 
wakefulness and normal life. I have several times seen excessive 
somnolence, lasting four or five months, during most of which 
time the patient was actually comatose, more or less thoroughly 
recovered from. In most of these cases hemianopsia, or motor 
palsy, or altered mental power, has remained to show that the 
brain had been permanently damaged. On the other hand, even 
in extreme cases the recovery may be complete. 

Syphilitic stupor ending in death usually puts on symptoms 
exactly resembling those of advanced brain-softening, to which, 
indeed, it is in most cases due. I have made three autopsies on 
such cases: in one there was symmetrical purulent breaking down 
of the anterior cerebral lobes ; in the second, softening of the right 
frontal and temporal lobes, due to pressure of a gummatous tumor ; 
in the third, softening and breaking down of the brain in the 
region supplied by the middle cerebral artery, probably as the 
result of an arrest of circulation. 

Group Second. The organic brain-diseases which produce 
stupor but are not associated with headache are not very numer- 
ous : prominent among them is dementia paralytica, in which dis- 
ease, however, the stupor does not come on until very late in the 
affection. In all forms of cerebral softening stupor or coma is 
finally developed, and if such softening be due to disease of the 
blood-vessels, to cerebral sclerosis, or to other affection which does 
not involve the brain-membranes or markedly increase the blood- 
pressure in the brain, headache is usually wanting. A rare but 
important affection, of which stupor is the most prominent symp- 
tom, is one which has not been heretofore generally recognized as 
a distinct disease, although cases of it have been reported. 



412 DIAGNOSTIC NEUROLOGY. 

There is so much unity of structure in the ganglionic cells 
throughout the nervous system that it can hardly be otherwise 
than that a pathological process which affects one set of these cells 
shall find its parallel in the disease of other cells. A sclerosis 
may attack any portion of the white matter of the nervous cen- 
tres, and in like manner I believe that the peculiar degeneration 
which occurs in poliomyelitis may assault the nervous cells of 
the cerebrum. Under the circumstances, loss of function, with 
or without evidences of primary irritation, must result. For 
this affection the name of Polioencephalitis is very suitable. 

In some cases of poliomyelitis fever and other evidences of con- 
stitutional disturbances are pronounced in the beginning of the 
disease; but it does not follow from this that the changes in the 
cells are due to acute inflammation, much less have we any proof 
that the slow alterations which occur in the subacute and chronic 
forms of the so-called poliomyelitis are inflammatory. 

It is probable that all these forms of poliomyelitis are repre- 
sented in affections of the cerebral cortex ; but the only cases of 
which I have knowledge in which the nature of the disease has 
been proved by post-mortem examination represent the subacute 
forms of the affection.* 

The palsy and the trophic changes of poliomyelitis are evi- 
dences of loss of functional power. Symptoms due to the irrita- 

* It is possible that the cases described by Dr. Adolf Striimpell {AUgemeiyie 
Wiener Med. Zeitung^ 1884, 29) under the name of encephalitis of childhood 
may represent the acute form of poliomyelitis ; but as in no case was an 
autopsy made, and as the symptoms closely resemble those of ordinary infan- 
tile spastic paralysis, the matter is open to much doubt, especially since Dr. 
Striimpell states that he has never seen the affection in its earlier stages, and 
has had to rely upon the statements of parents for the descriptions. Accord- 
ing to these statements, the sickness commences with fever, vomiting, and 
convulsions, or, in some mild cases, with a short convulsion and slight febrile 
reaction. This stage is said to last from two days to a nionth, during which 
time the parents have noticed paralysis of one-half of the body or sometimes 
of a single extremity. The hemiplegia is never complete, the paralysis often 
affecting groups of muscles and constituting a multiple palsy. There are 
no trophic changes, and in many cases facial or ocular palsy shows that the 
nervous system is affected very high up. After the acute stage had passed, 
at the period when the cases were seen by Dr. Striimpell, there were marked 
contractures, with increase of the reflexes. In some cases there was athetosis. 
Epileptic attacks were not infrequent, and not rarely there was marked mental 
degeneration. 



DISORDEES OF CONSCIOUSNESS. 413 

tion of the ganglionic cells seem to have no place in the affection, 
unless, indeed, the convulsions which usher in the attack be looked 
upon as of such character, but these are probably cerebral, and 
sympathetic local spasms do not occur, as should be expected if 
there were any persistent irritation of the motor ganglionic cells. 
In like manner the symptoms of polioencephalitis, at least of the 
subacute cases, are the outcome of failure of function. They may 
be summed up as failure and perversion of intellection, persistent 
stupor, muscular relaxation, anaesthesia, and, in cases which do 
not recover, death in a stuporous dementia. It is well known 
that in poliomyelitis partial or even complete recovery sometimes 
takes place, although the symptoms have seemed desperate, and 
it is probable that some of the cases of persistent stupor occurring 
among the insane, followed by more or less imperfect recovery, 
are instances of polioencephalitis. 

The following case is reported by Dr. Legrande du Saulle {Ga- 
zette des Hopitaux, 1869, xlii. 505). I conceive it to be a char- 
acteristic instance of subacute polioencephalitis. A man, aged 
thirty-two years, became melancholic during June, 1868. On the 
10th of September he went into a profound sleep. The extremities 
were rigid, the respiration rapid, the pulse seventy-two, and gen- 
eral sensibility very obtuse. About a week after this, general 
muscular relaxation developed, the cutaneous anaesthesia became 
complete, and intestinal inertia very pronounced. The respirations 
were from twenty-four to thirty-two a minute. By October the 
temperature of the body had fallen to ninety-six degrees, emacia- 
tion had become extreme, and the bowels were opened only once 
in ten or twelve days. On the 4th of November, after a blister 
to the head, he suddenly cried out, " My God, my God, have pity 
on me, for I am about to die !" but a moment afterwards relapsed 
into stupor. The pulse during October was forty-four a minute, 
but with his general condition began to improve, and by the close 
of November the pulse was nearly natural in frequency and the 
intestinal action about normal, but the stupor persisted. The 
urine was normal, except that it contained some excess of uric 
acid. Intoxication with alcohol, ether, and hasheesh failed to 
elicit any sign of mental life, as did also the efforts of a magne- 
tiseur. The optic papilla was very pale, and opaque from serous 
transudation. The man died of pneumonia in the latter part of 



414 DIAGNOSTIC NEUROLOGY. 

March. A thorough autopsy showed that the cerebral gray matter 
had changed color to a pale gray^ through which were scattered 
sharply-defined islets of excessive vascularity. The nerve-cells of 
the cerebral convolutions had almost completely disappeared. 

ACCIDENTS OF SLEEP. 

Under the head of accidents of sleep I propose to consider, 
briefly, first, certain curious symptoms which have no connec- 
tion with dreaming; secondly, certain states which are closely 
connected with dreaming. 

In the first division of the present subject the disturbances are 
chiefly sensory. The most important of them is that to which the 
name of sense-shock has been given by Dr. Mitchell. It is most 
frequent in hysterical women, but does occur in men, especially 
in those of a neurotic temperament who are overworked. It is 
usually felt at the time when the subject is passing from waking 
to sleep. A sensation like an aura rises from the feet, or, more 
rarely, from the hands, and passes upward to the head, where it 
disappears in the sense of a blow or shock, or of a bursting in the 
head : not rarely at the time of the explosion the patient hears a 
loud noise, or sees a vivid flash of light, or perceives a strong odor. 
In some cases two or even more of these sensory manifestations 
are present together. There is no loss of consciousness, and any 
motor symptoms which may occur are the outcome of the over- 
powering terror which is felt during the crisis and is sometimes 
manifested by a shriek. Occasionally a number of these shocks 
follow one another at short intervals. The paroxysms may occur 
during the daytime. These attacks may be excessively annoying^ 
but they have no serious significance, and are to be looked on as 
hysterical. 

A sleep-symptom which Dr. Mitchell states that he has seen 
in Duchenne's disease is that to which the name of night palsy or 
nocturnal hemiplegia has been given, — a name which seems to me 
improper and misleading, as the symptom is not connected with 
loss of motor power, and, in my experience at least, is never of 
serious import. I have frequently seen it in hysterical or neurotic 
women, especially at the time of the menopause, but never in or- 
ganic nervous disease. It consists simply of a feeling of numbness 
in one or more extremities of the body when the sleeper awakes. 



DISORDERS OF CONSCIOUSNESS. 415 

The most common seat is one arm ; but the symptom may be 
hemiplegic^ or may affect the whole body. It certainly is not the 
result of lying upon the part, nor is it any indication of heart- 
disease or of organic nervous disease. It appears to me ^-o be 
simply one of the numerous hysterical symptoms whose exact 
nature cannot be explained. 

Somnambulism, — Somnambulism is defined by Dr. H. Barth 
{Du Sommeil non-naturel, Paris, 1880) to be a dream with exalta- 
tion of the memory and of the automatic activity of the nerve- 
centres, combined with absence of consciousness and spontaneous 
will. It is common for a sleeper, be he either human or brute, 
to give evidence, by speech or by movement, of the dreams that 
are coursing through his brain. Such evidences may in the dog 
be no more than a bark, or an impotent running motion of the 
feet, or a wagging of the tail ; whilst in the man restless tossing, 
movements of the hands, or muttered words may be the sole indi- 
cation of what is going on within. A step beyond this, and the 
dreamer acts in accord with the drama which is being enacted in 
his imagination. Thus, a man strikes his wife in the belief that 
he is wrestling with burglars. Sometimes after such agitated 
movements, or in the midst of an apparently profound quiet re- 
pose, the sleeper rises from his bed, and, unclothed, or after first 
dressing himself, passes about his room, opens his door, goes out, 
or does other acts with continuous rapidity of movement. Every 
grade between the slightest dream-movement and the most active 
sleep-walking exists ; but whenever a dreamer rises from his couch 
he may be said to be a somnambulist. 

If the somnambulist be approached, his eyes will be found to 
be closed, or, if open, with the rest of the face they are impassible 
and without expression, paying no attention to the brightest lights, 
and appearing to have no power of sight in them : yet obstacles 
are avoided, narrow places passed through, feats of balancing per- 
formed, and numerous complicated movements made so perfectly 
that the by-stander can hardly persuade himself that the sleeper 
is not awake. When seized hold of, the somnambulist usually 
resists with vigor. Left to himself, after wandering for a greater 
or less length of time he returns to his bed, covers himself up, 
and sinks into the quiet forgetfulness of normal sleep. 

In the milder forms of somnambulism it is sometimes possible 



416 DIAGNOSTIC NEUROLOGY. 

to turn the thoughts of the sleeper by speaking to him, and in 
obedience to a firm command he will return to his bed without 
awakening. Shaken a little strongly, or aroused with a dash of 
cold water, he awakens slowly, and in a little time is conscious of 
his environment. 

In the more severe forms of somnambulism the paroxysm lasts 
for a considerable time, and during its continuance acts are per- 
formed which seem impossible to an unconscious man. Thus, the 
somnambulist will actively rehearse that which during waking 
hours occupies his thoughts and his acts. A parson will prepare 
his sermons, a student labor over his tasks, an artisan toil with 
his hands. Bourgarel {Union 3Ied., 1861) records the case of a 
sailor who would rise from his hammock, wander about the vessel, 
climb the masts, and high above the sea go through the duties of 
the foretopman. Barth recounts the case of a student whom his 
comrade saw get up and go into his study and compose a piece of 
Latin verse, but who on the morrow was ignorant of all that he 
had done, and reported to his professor that through lack of time 
he had been unable to perform his allotted task. Sometimes 
the somnambulist will reproduce by word, gesture, or act scenes 
which emotional excitement has impressed upon the nervous or- 
ganism. Such was the case of a young girl, cited by Barth, who 
would recount with detail in word and act a criminal assault from 
which she had suffered. 

Even in the mildest forms of the affection a somnambulist may 
be led by his dreams to acts of violence, and in the severer parox- 
ysms serious injury may result. 

Barth quotes a case originally recorded by Alfred Maury, in 
which a husband attempted to throw his wife out of the window 
whilst dreaming that his house was on fire. M. Fod6r6, in his 
treatise on medical jurisprudence, details a case related to him by 
a prior, who, going very late to bed one night, saw one of the 
brethren walk in his sleep up the entry, open the door of his (the 
prior's) room, and pass in. For a moment the somnambulist stood, 
with open, fixed eyes, and an expression of determined rage upon 
his face, and then marched to the bed with a drawn knife in one 
hand. Passing his unarmed hand over the bed, he seemed to feel 
the presence of some one in it, and then struck fiercely with the 
knife three times, forcing the blade through the bedclothes deep 



DISORDERS OF CONSCIOUSNESS. 417 

into the mattress. After this, with an air and expression of 
great satisfaction on his face, he turned and went back to his own 
bed. The light of two lamps shone in the room, and apparently 
fell directly upon the eyes of the somnambulist, but elicited no 
response. The next morning the prior sent for the brother, who, 
on being urgently questioned, said that he had had a frightful 
dream the night before. He had dreamt that the prior had 
killed his mother, that her bloody ghost had appeared to him 
demanding vengeance, and that under its direction he, in a trans- 
port of fury, had forced his way into the apartment of his superior 
and killed him with a poniard. He ended his account by ex- 
pressing the immense relief which he had experienced when he 
awoke and found that all was but a dream. 

A case which ended more tragically was tried before the Eng- 
lish courts, and was reported by Dr. Yellowlees in the Journal of 
Mental Science for October, 1878. The history was that the family 
of the prisoner, while he was still a mere lad, lived alongside of a 
rushing torrent, and that often he would arise in his sleep and go 
to the landing-place, and even into the water, loudly calling his 
favorite sister by name, feeling out with his arms as if rescuing 
her from drowning. Sometimes the water awoke him, and some- 
times it did not, but after his efforts he would go quietly to bed. 
As his life went on, he became more and more liable to seizures of 
night- walking, which finally settled down into a common type. 
During his sleep terror would seize upon him, and he would start 
out of bed to escape or put aside the impending evil. In his 
dreams the house would be on fire, the walls would be crushing 
him, or his child would be falling down a pit, or still more fre- 
quently a wild beast had come into the room and was about to 
devour him : roaring frantically, and in an agony of fear, he would 
tear his wife and child from the bed and fiercely chase the wild 
beast through the room, throwing the furniture about, and striking 
wildly with any weapon that he could reach. On several occa- 
sions he had seized a companion by the throat and strangled him 
almost to death, under the idea that he was struggling with the 
wild beast. In some of these paroxysms he would hear and 
answer distinctly. One night he saw a large white beast fly up 
through the floor and pass towards the bed where the child lay : to 
save it he gripped it by the breast, and, roaring with terror, hurled 

27 



418 DIAGNOSTIC NEUROLOGY. 

it against the wall with such force that it fell dead. That the 
paroxysm resembled an attack of epileptic delirium is apparent; 
and Dr. Echeverria {Journal of Mental Diseases, January, 1879) 
attempts to prove that the patient really suffered from nocturnal 
epilepsy. The fact, however, that the man could be awakened 
during the paroxysms indicates very strongly that the attack was 
not a pure epilepsy, which is confirmed in a measure by the total 
absence of epileptic phenomena during the daytime. The uri- 
nary incontinence which Dr. Echeverria speaks of as having been 
present and as evidence of the epileptic character was, according 
to the report of Dr. Yellowlees, essentially different from the 
incontinence of nocturnal epilepsy. It occurred only during 
childhood, and entirely independently of the paroxysm, and was 
simply the incontinence of a feeble, neurotic child.* 

The so-called night-terrors of childhood, although frequently 
spoken of as a distinct affection, are, in truth, only a form of 
somnambulism, or, in rare cases, epileptoid seizures. Nothing 
is more common than for a young child to go in the night to its 
parents' bed, trembling with terror or weeping bitterly, with the 
statement that it has had a bad dream. Such a dream may be so 
vivid as completely to enchain the attention, and if at the same 
time there be outward manifestations of the overpowering emo- 
tions from which the child is suffering, a paroxysm of night-terror 
results. With screams and imploring calls upon its mother for 
assistance the child struggles and cannot be aroused or comforted, 
but at last slowly awakes, or, much more infrequently, falls again 
into peaceful slumbers. Very frequently, even during the par- 
oxysm, the child shows terror of some one object : a cat, a dog, a 
white elephant, a monster of some kind, is indicated by its in- 
coherent cries. In a large majority of cases night-terrors are not 
connected with any organic disease of the brain or with epilepsy, 

* Medico-legally this case is of great interest. Put on trial for his life, the 
man pleaded, '* I am guilty in my sleep, but not guilty in my senses," and the 
jury found that the man was unconscious of the nature of the act which he 
committed by reason of a condition arising from somnambulism, and that he 
was not responsible. The man certainly was not insane in the ordinary sense 
of the word, and just as certainly he was not responsible. These cases are so 
exceptional that I believe no country has as yet a law applicable to them. 
Probably the best that a court could do would be to consider the alleged 
criminal as having been temporarily insane. 



DISORDERS OF CONSCIOUSNESS. 419 

and are of no more serious import than an attack of somnam- 
bulism. They usually depend upon some peripheral irritation : 
especially are they commonly the result of a gastro-intestinal irri- 
tation from undigested food. Hence they frequently follow heavy 
suppers, or overeating of some kind in the latter part of the day. 
Not rarely they occur during active dentition, and are relieved by 
cutting of the gums. In a few recorded cases the cause of the 
attacks has been intestinal worms. The overpowering emotion 
of the night-terror is sometimes the result of a fright during 
the day, as in the case reported by Meigs and Pepper, in which 
a child, who had been bitten by a parrot, on several successive 
nights sprang up out of a sound sleep shrieking, '^ Take the parrot 
away ! take the parrot away !'^ I have seen in adults somnam- 
bulism perfectly parallel to this. Thus, after a house was robbed, 
a woman for several nights arose and walked in her sleep, trying 
to escape from burglars and raise an alarm. The night- terror is, 
I think, only a form of somnambulism. 

Night-terrors which are the outcome of serious brain-disorder 
are rare, and not to be positively distinguished by their symptoms 
from those of less serious import. They, however, frequently 
recur several times a night, and continue for many weeks ; whilst 
the night-terror of irritation usually happens only ouce, and ex- 
tremely rarely more than twice, in a single night, and does not 
continue to recur for weeks, except it be at considerable intervals. 
Moreover, the serious night-terror is almost invariably accom- 
panied by other manifestations of disorder of the brain-action, 
which point out its true meaning. Dr. F. Debacker {These, Paris, 
1881) has reported the case of an infant, who finally died of 
tubercular meningitis, in whom the earlier symptoms were night- 
terrors, which were, however, usually associated with spells of 
fright during the day, and with distinct evidences of hallucina- 
tion. In the same thesis is recorded an instance in which the 
nocturnal terrors occurred in a child four years of age and were 
associated with a rapid loss of power which ended in idiocy ; and 
also a case in which the outcome was epilepsy. 



CHAPTER XL 

DISTURBANCES OF INTELLECTION. 

For the purpose of studying the symptoms of mental disorder 
the human intellectual faculties may be separated into the will, 
the intellectual faculties proper, such as reason, imagination, etc., 
and the emotions, such as fear, anger, etc. 

Disorder of one mental faculty is almost invariably accompa- 
nied by a greater or less degree of disturbance of the other mental 
faculties, but, a priori, there seems to be no reason why one faculty 
of the mind should not suffer alone, and cases are said to occur 
in practice in which a single faculty appears to be under the in- 
fluence of disease when no other evidences of mental disorder can 
be detected. 

The human will acts chiefly upon the lower intellectual and 
emotional brain-functions as a repressive force. It inhibits or 
puts aside this thought or that distraction or this emotion, rather 
than brings forward another thought or emotion. We cannot 
will ourselves into a passion, though we can by a direct effort of 
the will inhibit or repress a rising anger. If we desire to pro- 
duce a fit of anger, we do it by bringing before the mind thouglits 
which act as stimulants to the desired emotion : the almost uncon- 
scious recognition of this fact has led to the expression ^' work- 
ing one's self into a passion." As is usually the case in disorders 
of inhibitory nerve-function, affections of the will are most plainly 
and frequently manifested by weakness or failure of power. The 
excessive obstinacy and self-assertion seen in certain forms of 
insanity indicate a condition of abnormal exaltation of the will. 
Generally, however, extravagances of thought and action which 
appear to point to an excessive activity of the will are really due 
to the overpowering action of some emotion or some idea which so 
dominates the will as to govern entirely the actions of the indi- 
vidual. The obstinacy and self-assertion are under these circum- 
stances really the outcomes of a weakened will rather than of an 
overpowering egoism, — the person being obstinate or aggressive 
420 



DISTURBANCES OF INTELLECTION. 421 

because his will is enslaved by a lower intellectual or emotional 
nerve-centre. Thus, in melancholia inflexible obstinacy may re- 
sult from the absolute despotism of an overwhelming sorrow. 
In hysteria the will is probably always abnormally feeble^ but 
the persistence and apparent wilfulness of hysterical subjects are 
proverbial. 

Weakness of the will is produced by various organic brain- 
diseases, which lower the nutritive tone of the cerebral cortex. 
It is caused very frequently by chronic poisonings, being one of 
the most pronounced symptoms of alcoholism and of opiumism. 
Under these circumstances the subject may show an extraordi- 
nary persistency when dominated by his appetite, and yet is really 
most infirm of purpose, entirely unable to decide upon a course of 
action in regard to ordinary matters, or to carry out his decision 
when reached. He is liable to be inordinately influenced by his 
associates and by his environs, cannot resist entreaty and temp- 
tation, and so becomes more and more the sport of his desires and 
of external influences. 

Acute illness, starvation, hardships, age, chronic diseases, any 
influence which lowers the nutrition of the higher nerve-centres, 
may produce weakness of the will. So varied are the causes 
which may produce the so-called abulia, or abnormal weakness of 
the will, that it has no further diagnostic import than to show a 
serious functional or structural alteration of the cerebral cortex. 

Exaggeration of the will-power is known as hyperbulia, and 
shows itself in some forms of mania and of cerebral cortical 
excitement. 

The emotional nature may be by disease depressed, exalted, or 
perverted ; the alteration often aifects persistently a single emotion 
or a single class of emotions, or it may attack successively, at 
shorter or longer intervals, emotions that are antagonistic. Thus, 
a subject may be in a continual state of joy or of emotional de- 
pression, or he may rapidly or slowly pass from one state of emo- 
tional excitement to another, now carried away by anger, now 
prostrated by fear, now soaring with joy, now overwhelmed by 
sadness. 

In advanced stages of cerebral disease a condition of true emo- 
tional enfeeblement or lethargy may be present, so that external 
circumstances which naturally affect most vividly this or that 



422 DIAGNOSTIC NEUROLOGY. 

emotion fail to produce any response. This mental condition 
ought logically to be known as emotional depression. It is to be 
clearly distinguished from excitement or overactivity of the depres- 
sive emotions, such as sorrow and their congeners. Viewed in this 
way, the melancholic person is not in a condition of emotional de- 
pression, but in one of emotional excitement, — i.e., of excitement 
of the depressive emotions. Melancholia is, it is true, frequently 
associated with depression of the nervous system, but this is not 
always the case, and the victim of melancholia agitata may be in 
a condition of general nervous erythrism as pronounced as that 
which aflFects the maniac with wildly-expansive delusions. On 
the other hand, high hopes and abundant joy are in advanced 
general paralysis closely linked with the most profound evidences 
of failing nerve-power. If melancholia is to be considered a 
state of lowered emotional activity, whilst joy and anger are the 
outcomes of emotional excitement, it logically follows that the 
antagonistic emotions are different manifestations of one cerebral 
function, joy being the result of excessive stimulation, sorrow of 
excessive depression, of the same brain-cells, — a conclusion which 
I think few persons would be ready to accept as correct. 

The relations between the diverse emotions of which I have just 
spoken are of some importance as explaining the fact that in vari- 
ous mental affections mania and melancholia, or opposite emotional 
states, may follow each other, and even appear to be produced 
by the same brain-lesion. Thus, in paretic dementia the persist- 
ent hypersemia of the brain-cortex may cause throughout the attack 
intense sadness, or an emotional depression may suddenly replace 
the expansive happiness usual to the affection. To account for 
such a change it is only necessary to suppose that there is a shift- 
ing of the hypersemia and the excitement from one portion of the 
brain to another. 

The intellectual functions proper may suffer from actual ex- 
altation, giving rise to increase of power; from an exaltation 
which is so unbalanced as to produce a derangement of action ; 
from a real depression or loss of power. 

Absolute increase of mental poteen* is a rare condition, and is 
never present in any advanced stage of disease. It does, how- 
ever, sometimes occur. The subject of a pronounced mental exal- 
tation has a passion for intellectual labor, accompanied by a corre- 



DISTURBANCES OF INTELLECTION. 423 

spending power of accomplishment. It is no longer an effort to 
fix the attention upon an intricate subject for successive hours. 
The sense of fatigue is lost, and the brain works on without pain, 
the quality as well as the quantity of the result being beyond that 
which the individual in his normal condition can produce. This 
state of mental exhilaration sometimes comes on during pro- 
tracted mental labor. It is probably always associated with 
hypersemia of the brain-cortex, and is usually accompanied by 
pronounced insomnia. It is a very dangerous condition, and 
should be the signal for immediate cessation of mental effort and 
for medical treatment. It is sometimes developed without obvious 
cause as a prodrome of severe mental disease. Thus, I have seen 
it precede a fatal outbreak of acute phrenitis, and it may usher 
in paretic dementia. 

If one or more of the mental functions are excited entirely be- 
yond the control of the will, and judgment becomes impossible, a 
mental condition is produced which in its most severe acute form 
is sometimes spoken of as delirium, and in its milder or more 
chronic forms as insanity. 

Failure of the mental poicers is a very common result of func- 
tional and organic brain-disease. When complete it constitutes the 
condition known as dementia. 

It is often of vital importance to recognize the dawnings of 
mental failure. The failure usually manifests itself first in loss 
of memory. This has already been sufficiently discussed (see 
page 369). Next to memory in the order of implication, and 
sometimes even preceding it, is the power of fixing the attention. 
The mind of man naturally wanders from subject to subject. A 
continuous thoughtful application depends upon the exertion of 
the inhibitive power of the will in repressing distracting thoughts 
and shutting out new perceptions. The power of persistent at- 
tention to one subject is to a great extent acquired by training. Its 
exercise is a large feature in all severe intellectual work. Conse- 
quently, when the brain is exhausted not only do the reasoning 
faculties labor with difficulty, but increased effort is required from 
the weakened will to maintain the necessary fixity of attention. 
Mental toil becomes, therefore, most irksome, as is recognized 
by the common expression of sufferers that '* work is becoming 
more and more of an effort.^^ Failure of memory and failure of 



424 DIAGNOSTIC NEUROLOGY. 

the power of fixing the attention have no particular diagnostic 
import. When they coexist and are associated with any other 
evidences of mental derangement, they indicate a serious disease 
of the brain itself. The loss of the power of fixing the attention, 
however, when it exists alone, usually depends upon simple cere- 
bral asthenia, — a condition in which there may also be some loss 
of memory. 

A symptom which may depend upon either mental excitement 
or loss of mental power is incoherence. An incoherence due to a 
heightened but irregular cerebral activity results from the ex- 
cessive rapidity of the intellectual acts, as well as from their dis- 
connected sequences. Before one idea is fully translated into 
words, another rushes into expression, and a hopeless confusion of 
talk results. The ideas tumble out as it were over one another. 
Incoherence from lack of mental power, on the other hand, arises 
either from the inability to complete the mental act or from the lack 
of the power of translating it into suitable words. In typical cases 
there is little difficulty in distinguishing between these varieties, 
which it is allowable to call respectively active and jxissive inco- 
herence. Tlie rapid utterances of the raving maniac usually show 
most plainly that his mind is pouring out broken hints of an infinite 
series of jostling ideas; whilst the slow, confused, disconnected, 
hesitating words of the dement no less unmistakably portray his 
inability fully to conceive an idea and embody it in words. There 
are, however, cases of disease in which mental excitement coexists 
with failing power, and in which, therefore, the incoherence is of 
mixed type. 

Human character is the result of the established balance be- 
tween the will, the intellectual attributes, and the emotional forces 
of the individual. When any of the correlated factors are 
altered there must be a corresponding change in character. Char- 
acter is, therefore, always seriously implicated in mental affections. 
Not rarely changes in the intellectual or emotional nature so sub- 
tile or hidden as not to be readily perceived register themselves 
with astounding distinctness on the dial-plate of character. Hence 
alterations of character are of the weightiest diagnostic import. 
They may be the first evidences of a developing pure insanity, 
but when sudden and severe they usually point towards dementia 
paralytica. A primary sudden criminal outbreak in dementia 



DISTURBANCES OF INTELLECTION. 425 

paralytica is generally sexual in its direction. Thus^ in a case now 
under my care the first marked disorderly action was an attempt 
to rape a servant-girl. After this it was discovered that very 
large and foolish purchases had been made as the begin nino- of a 
grand business scheme entirely foreign to the daily occupation of 
the man. An estimable citizen goes to a distant city and attempts 
to turn a hotel into a bawdy-house. Another^ whilst still per- 
forming acceptably the duties of an important public office, tries 
to seduce, and, this failing, to rape, his own daughter. 

In dementia paralytica, as in the pure insanities, the moral 
degradation may, however, run in other than sexual channels. 
The temperate man suddenly becomes addicted to drink; the 
honest man all at once appropriates large sums of money, which, 
it may be, he spends in licentious revels; he who has always 
been exceptionally self-controlled becomes violently passionate; 
the amiable, loving husband and father changes into a household 
demon. Careful examination under these circumstances will usu- 
ally detect other symptoms of paretic dementia. The evidences 
to be searched for are failure of memory, deterioration of mental 
faculties, inequalities of the pupil, perceptible loss of physical 
endurance or of the power of doing fine, complex physical acts, 
habitual emotional states of bien-etre, and a tendency to expansive 
delusions, as shown in the subject^s estimate of his own powers, 
business prospects, or schemes, and of the value of his possessions 
or surroundings. Whenever any of these things can be found, it 
is the physician's duty to give warning to the friends of the pa- 
tient, and, with their assent, to act. There are certain specific 
symptoms whose relation to cerebral diseases is so close and so 
important that they demand very careful consideration. These 
symptoms are naturally divided into two sets : first, those which 
indicate disorder of the perceptive faculties ; secondly, those which 
are connected chiefly with the intellectual and emotional spheres. 
Under the first head I shall consider Hallucinations and Illusions ; 
under the second head. Delusions, Imperative Conceptions, Mor- 
bid Impulses, and Morbid Desires. 

An Hallucination is the perception by any of the senses of an 
object which has no existence. It is the conscious recognition 
of a sensation of sight, hearing, feeling, taste, or smell which 
is not due to any impulse received by the perceptive appa- 



426 DIAGNOSTIC NEUKOLOGY. 

ratus from without, but arises within the perceptive apparatus 
itself: in other words, an hallucination is a subjective sensation 
which assumes the definite attributes of an objective sensation. 
It is commonly simple, — i,e., connected with a single sense. Thus, 
the vision is usually seen, not seen and felt. The false voice is 
heard, the mysterious presence is felt, but the presence and the 
voice usually do not coexist. In the order of their frequency 
of implication the senses may be enumerated as follows : sight, 
hearing, touch, smell, taste. The particular characters of the 
perceived object vary indefinitely, and involve the whole range 
of perceptions. Every variety of color and form, of sound and 
odor, of feeling and taste, may be perceived. 

In some cases, as in mirage, a false perception may amount al- 
most to an hallucination; that is, an impulse from without may 
give rise to such a distorted misleading conscious perception that 
the person really sees or feels or hears that which has no exist- 
ence. A distorted sensation, or, in other words, the perception of 
an object in characters which it does not possess, is frequently 
spoken of as an illusion. In nature there is no sharp line be- 
tween illusions and slight distortions of the perception of objects, 
or between illusions and hallucinations. An hallucination may 
be caused by an external stimulus so slight that it cannot be dis- 
covered, but it may arise entirely from witlnn the nervous system. 

An hallucination has no definite diagnostic import. It may 
come from exhaustion of the nervous system, especially when 
there is at the same time an intense desire. Thus, the wife, worn 
out with long watching and grief, sees in obedience to her yearn- 
ings the living form of her dead husband. The monk, exhausted 
by long prayer and fasting, if consumed by ardent devotion, is 
visited by saints or angels, or, if he be tormented by suppressed 
sexual desires, is haunted by troops of tempting devils or volup- 
tuous sirens. The person perishing with thirst sees or hears cool 
springs, babbling brooks, or plashing fountains ; gorgeous feasts 
float before the vision of the starving, and the shipwrecked mari- 
ner is tantalized by rescuing barks. 

Hallucinations may be the result of the immediate action of a 
poison, as in the beatific visions of the hasheesh-eater, or may 
be the outcome of the peculiar nervous state which follows the 
abuse of narcotic stimuli, as in delirium tremens. Conditions of 



DISTURBANCES OF INTELLECTION. 427 

the nervous centres at present inexplicable may call hallucina- 
tions into being, as in hysteria. More rarely the hallucination 
is the result of an organic brain-disease, when its nature is almost 
invariably pointed out by coexisting symptoms, such as epileptic 
paroxysms or local palsy. The structural alteration in such cases 
is commonly in the nerve-tract especially connected with the 
affected sense. 

An hallucination does not depend upon or prove the existence of 
intellectual unsoundness. It is, however, very apt to be associated 
with such unsoundness, because the condition of the sensory brain- 
tract which produces it is apt to accompany a similar condition 
of the higher or intellectual centres. Moreover, it often affords us 
a means of testing the condition of the brain-centres. If the 
judgment fails to correct the testimony of the disordered sense by 
that derived from other senses, the subject is of unsound mind. 
When, for example, the individual believes that the vision that 
he sees or the voice that he hears really exists, then is his judg- 
ment dethroned. It will be readily seen that in such a case it is 
not the seeing of the vision, but the loss of the power of weigh- 
ing evidence, that is the proof of the intellectual degradation. 
As will become very apparent during the discussion of delusions, 
the hallucination, in the case just imagined, has given rise to a 
delusion. 

The word delusion may be defined to be a false belief, but as it 
is used by alienists the term means something more than this. By 
Spitzka the insane delusion is said to be '' a faulty belief out of 
which the subject cannot be reasoned by adequate methods for the 
time being.^' The objection to this definition is that there are 
many faulty or false beliefs held by perfectly sane persons out of 
which such persons cannot be reasoned, but which are not insane 
delusions. Thus, either the Christian or the Mussulman, under 
such definition, is the victim of an insane delusion. To meet the 
necessities of the case the definition should be modified so as to 
read, ^^A faulty belief concerning a subject capable of physical 
demonstration, out of which the person cannot be reasoned by 
adequate methods for the time being.^^ 

The parallelism between a delusion and an hallucination is very 
close. A delusion is a false belief. An hallucination is a false 
perception. The delusion becomes an insane one only when the 



428 DIAGNOSTIC NEUROLOGY. 

false belief cannot be dissipated by absolute proof of its incorrect- 
ness. The hallucination becomes an insane one only when the 
false perception cannot be corrected by the judgment through the 
other senses. In either case the essence of the insane mental state 
is loss of power to receive and weigh adequate evidence. 

Thus, John Smith hears voices where there are none; he is 
insane only when he is unable to correct the evidence received 
through the sense of hearing by that received through the senses 
of sight and feeling. If he persistently believes that persons speak 
to him, although he cannot see or touch them, his judgment is in 
abeyance. On the other hand, John Jones believes that a certain 
barn exists upon a certain field where there is no barn. Under 
these circumstances he has a delusion, a belief which has grown 
up in his mind from some cause unknown. Now, if, when taken 
to the field, he is incapable of receiving the evidence of his senses 
and persists in his belief that the barn is there, he is insane ; but 
if he receives the evidence of his senses and perceives that the 
barn does not exist, he is not insane. In case of insane hallucina- 
tions or delusions, the truth or falsity of the vision or of the belief 
is not essential. The essential thing is the condition of the mind 
of the individual, — a condition which prevents it from receiving 
evidence. Hence an insane belief may be true although insanely 
held. 

In the supposititious case given above, assuredly the mental 
state of the individual is in no wise dependent upon the absence 
of the barn, although such absence renders a test of the subject's 
mental condition possible. The distinction just drawn may seem 
unimportant and so trite as to be unworthy of discussion, but 
the failure to understand it has been one cause, in my experience, 
of the inability on the part of learned lawyers to comprehend the 
subject of insanity. 

Not long ago, after due process of law, an insane man by the 
name of Taylor was hung in Philadelphia for the unprovoked 
murder of a prison warden. It was in evidence that the man 
believed that all the attendants of the prison were Catholics and 
were " down on'' him because he was a Protestant, and were de- 
stroying him. The prosecuting attorney asked, ^' Supposing it were 
proved that the prison attendants were Catholics, would it not 
have to be acknowledged that the man's belief was correct, and 



DISTURBANCES OF INTELLECTIOlSr. 429 

that he was not insane ?" Apparently neither lawyer nor judge 
could be made to understand that the falsity or the truth of the 
prisoner's belief in the Catholicism of the attendants had little 
to do with the question of his insanity. It was proved that he 
had other delusions of persecution, and his having adopted a 
belief in regard to the Catholicism of his attendants which was in 
accord with such delusions, without any evidence of their alleged 
Catholicism, and having reasoned insanely upon the subject and 
acted in accordance with conclusions so reached, showed that his 
action rested upon mental unsoundness. Surely the " because I 
am a Protestant, therefore they were destroying me/' ought to 
have made the mental condition of the prisoner clear. In the 
language of Spitzka, ^^ Repeatedly does it occur in the alienist's 
experience that the facts of a case and the delusion happen to 
correspond." This is well illustrated in a case reported by him. 
An artist's model asserted that he was the finest-built man in 
the United States. He really had a magnificent figure, but his 
announcement was, notwithstanding, that of a paretic dement, 
for inquiry elicited the statement that the "girls looked at him 
because he had a peculiar expression in his eyes which they 
fancied," and he revealed other unmistakable evidence of general 
paralysis. 

An insane belief or delusion may rest upon an hallucination, 
may be built upon a foundation of disordered sensation, may 
spring from the most trivial circumstance, or may, so far as can 
be judged, be self-engendered in the mind. Thus, the voice that 
is heard as an hallucination gives rise to the delusion of an ever- 
present persecutor; a persistent distress in the abdomen, to a delu- 
sion of pregnancy, or that the bowels are dropping out, etc. The 
following case from my note-book illustrates very forcibly the 
curious way in which a delusion develops in the mind without the 
slightest foundation in verity. A man after a malarial fever be- 
gan to have suspicions in regard to the chastity of his wife. For 
a time he kept these to himself, but finally he accused her of infi- 
delity. After this had continued for some weeks he presented 
himself with his wife at my clinic, saying to me, "I think 
my wife goes with other men. She thinks I am crazy. I am 
uncertain whether she or I am right." On being questioned, he 
stated that he first noticed her looking behind her, as though she 



430 DIAGNOSTIC NEUROLOGY. 

were looking for some one, when they walked together; that he 
afterwards saw a handkerchief lying on the bureau in her room, 
just as she would have left it if she had been flirting with some 
one out of the window, and that when he saw a chair by the win- 
dow of her room and a man at the corner of the street he was 
convinced that his suspicions were correct ; in this he was cor- 
roborated by finding three dollars in a trunk, which he believed 
his wife had received ^' for evil courses," although she had declared 
that he himself had given it to her. He further stated that he 
watched her eyes. In a very eager, tremulous manner he said, 
" I got a lamp, and when I found her eyes were dark beneath I 
told her there was something wrong with her, and then she began 
to think there was something wTong with me. I firmly believed 
she was going with other men.^' The man had an inherited 
tendency towards insanity, and had lost much sleep. When his 
whole case was thoroughly explained to him, he said that he "now 
understood it, and was glad to hear it, and that it gave him power 
to brace himself against the notion," ending with the assertion that 
he believed that " he had a good woman." In reply to a question, 
he said, " I do not think there is danger of my hurting my wife, 
but these things come on me so that I cannot control myself at 
times, and I am willing to go to an asylum if it is thought to be 
right." 

The relation between the emotional state of an insane man and 
his delusions is very close. Expansive or happy delusions ac- 
company emotional exaltation, while horrible or sorrowful delu- 
sions go hand in hand with depressive emotions. Thus, the mel- 
ancholic woman is oppressed with the belief that she is hopelessly 
damned, that her husband is unfaithful, or that she is pregnant 
with devils ; whilst the maniac, overflowing with animal spirits, 
is a prophet sent of God, is owner of uncounted millions, or 
mayhap is about to become the mother of the Messiah. The 
emotional state and the delusions constantly react upon one 
another. Some alienists believe that the character of the delu- 
sion is directly dependent upon the dominant emotion ; but it 
seems to me more probable that the characters of the emotions 
and of the delusions are the result of a common cause, rather 
than that either governs the other. 

The nature of delusions varies so indefinitely as to render any 



DISTURBANCES OF INTELLECTION. 431 

attempt at a thorough classification futile. There are, however 
certain classes of delusions which are so frequently met with and 
so characteristic as to require especial study. The most important 
of these are — 1. Expansive Delusions. 2. Hypochondriacal De- 
lusions. 3. Delusions of Persecution. 

Expansive Delusions usually concern the personality of the 
individual who has them, either as to his prowess, his mental 
or physical attainments, his possessions, or his future prospects. 
The patient boasts that he is the strongest man in the world, 
asserts that his mental powers are immense, or that he is a king 
or other notability, or more commonly talks of his millions of 
money, his gold-mines, his farms of unlimited extent, his vast 
stables full of unnumbered horses of the choicest breeds, his far- 
reaching and gigantic business schemes, etc. This condition con- 
stitutes the delire de grandeur^ and, whilst in the majority of 
cases it depends upon the existence of general paralysis, it may be 
present in many forms of mental disease. I have seen it very 
pronounced in cerebral syphilis, and have watched the millions of 
dollars possessed by the subject shrink to thousands, and the thou- 
sands to hundreds, as the brain-lesions grew less under the ad- 
ministration of mercury. Then even the hundreds disappeared, 
and his ow^n poverty w^as confessed ; but the assertion still re- 
mained that '^ his uncle w^as worth a million,'^ until at last this too 
vanished in the recognition of the desolate truth. 

Hypochondriacal Delusions relate to disease of the person of 
the patient, and are usually, but not always, associated with a 
depressive emotional state. They sometimes rest upon a sub- 
stratum of ill feeling, or even of actual disease, in the part alleged 
to be hopelessly affected. They are often obviously absurd, as 
that the legs are made of glass. Of all forms of delusion this 
is the one in which the gradations between the sane and the in- 
sane belief are most subtile. Every step can be found between 
the slightest exaggeration of symptoms and the hypochondriac 
foundationless belief. Unless a hypochondriacal delusion is upon 
its face absurd, the physician must be very careful in basing upon 
it an opinion that the subject of it is irresponsible, since many 
invalids are hypochondriacs and have exaggerated beliefs border- 
ing closely upon delusions, but are, nevertheless, of sufficiently 
sound mind for the performance of the ordinary duties of life. 



432 DIAGNOSTIC NEUROLOGY. 

Delusions of Persecution are common in melancholia, but are 
not always associated with a pronounced depressive emotional 
condition. They are always the source of great annoyance and 
distress to the subject, and are usually associated with hallucina- 
tions, which I think are most apt to be connected with the sense 
of hearing. Very commonly obscene, reproachful, or threaten- 
ing voices are heard at all times and in all places. Usually the 
delusion of persecution does not attach itself in the mind of its 
victim to one person, but to classes of people or to unseen spirits. 
Sometimes, however, the delusion does affix itself to one individ- 
ual, as in a recent case in which a woman travelled across the 
continent of America to kill a doctor who she believed was 
placing a spell upon her. Of all the quiet classes of the insane, 
those who have delusions of persecution are the most dangerous. 
They are impelled by motives of revenge and of fear to kill those 
who are persecuting them. This is especially the case when the 
delusion attaches itself to one individual ; but even voices in the 
air may lead to sudden violent assaults upon by-standers who are 
for the moment thought to be the source of the words. More- 
over, the lunatic may at any time fix in his mind upon any 
acquaintance or notable person as the origin of his persecution 
and make his plans in accordance. 

A very important division of delusions is into systematized 
and unsystematized. A systematized delusion is one concerning 
which the subject reasons, and which he defends more or less 
logically. Any character of delusion may be systematized. If a 
lunatic asserts that he is worth a million of dollars and simply 
sticks to his belief when it is denied, he has an unsystematized 
delusion of grandeur; but if he should attempt to defend his 
delusion by describing how he had inherited his wealth or how he 
had acquired it through investments or business ventures, his de- 
lusion would be systematized. Again, a person suffering from 
melancholia believes that his soul is lost. If, when opposed, he 
simply reavows his belief and assigns no reasons for it, his de- 
lusion is unsystematized ; but if he says he is lost because he has 
committed the unpardonable sin, quotes Scripture to show that 
such a sin warrants his doom, and perhaps tells why and when he 
sinned, his delusion is systematized. 

Great diagnostic value has been attached by some recent writers 



DISTURBANCES OF INTELLECTION. 433 

to the distinction between systematized and unsystematized delu- 
sions, and much has been predicated upon it in the classification 
of insanities. According to my experience, however, in nature 
every gradation is to be found between the most thoroughly sys- 
tematized delusion and that which is most completely isolated. 
I have seen various cases in which it was doubtful whether the 
delusion should be classed as systematized or unsystematized ; and, 
whilst I acknowledge that in typical partial insanities the delu- 
sions are systematized and in typical general insanities they are 
unsystematized, I am of the opinion that in this character, as in 
others, the two groups of general and partial insanities pass in 
nature insensibly into each other. 

There are certain conceptions or general ideas which may arise 
in the brain of a person, and to a greater or less degree dominate 
his actions, although the reason may not be unsettled, and the fal- 
sity of the conception may be recognized by the individual whom 
it controls. Such a phenomenon is known as an Imperatke Con- 
ception, and differs from a delusion in that its falsity is recognized, 
although the individual is powerless to withstand its influence. 
Closely allied to the imperative conception is the Morbid Impulse. 
Some alienists, indeed, teach that the imperative conception gives 
rise to the morbid impulse. In certain cases this undoubtedly 
happens, as when the imperative conception of personal defilement 
gives origin to the impulse of escaping from that which defiles; 
but a morbid impulse may arise without any discoverable imper- 
ative conception. Thus, I long had under my care a man in 
whose family insanity was distinctly hereditary, but in whom the 
only symptom that I could find was an impulse to assault by- 
standers, — an impulse apparently born of no reason, altliough felt 
with such urgency as to fill the patient with a terror of himself. 
Once, upon returning home, I found this man sitting in my office 
terribly excited, and greeting me with, " Doctor, doctor, I nearly 
did it ! I nearly did it V It appeared that he had spent forty- 
eight hours without intermission in a vortex of political excite- 
ment, and suddenly the impulse to kill had come on him with 
such power that only by fleeing to my ojffice was he able to save 
himself. The impulse to throw one's self from a precipice, caused 
by standing on its brink, is a familiar instance of a mild morbid 
impulse without an apparent foundation of an imperative con- 

28 



434 DIAGNOSTIC NEUROLOGY. 

ception ; whilst the reasonless dread which many persons have 
of a snake, toad, cockroach, or other harmless creature probably 
depends upon an incipient imperative conception of personal 
defilement. 

The act which results from a morbid impulse is sometimes 
spoken of as an Imperative Act An imperative conception is 
viewed by some alienists as an '' undeveloped delusion.^^ It is, 
however, not a proof of general mental unsoundness, but in 
some cases finally the reason of the patient fails to recognize 
the untruthfulness of the imperative conception, which concep- 
tion thereby becomes converted into a delusion, precisely as an 
hallucination may give rise to a delusion. 

A very important and common imperative conception is a mor- 
bid fear. This may take almost any form, and may be simply 
an exaggeration of a normal feeling or may arise de novo. Thus, 
in some persons the fear of a thunder-storm is so violent as to 
destroy for the time being all rationality; in others the natural 
dislike of filth is increased until it dominates every action of life. 
On the other hand, the horror of walking in an open place, which 
is sometimes so overwhelming, seems scarcely to be based upon 
any natural feeling. To many of these morbid fears names have 
been given by systematic writers. The fears, however, vary so in 
their detail that it is not possible to express them accurately and 
fully by any system of nomenclature. A few of these names 
may be cited, as representing the more characteristic forms of 
morbid fear. The following list, taken from Dr. Beard, portrays 
very well the absurdities of nomenclature : 

Astraphobia, fear of lightning. Topophobia, fear of places, — 
a generic term, with these subdivisions : Agoraphobia, fear of open 
places; Claustrophobia, fear of narrow, closed places. Anthro- 
phobia, fear of man, — a generic term, including fear of society. 
Gynsephobia, fear of woman. Monophobia, fear of being alone. 
Pathophobia, fear of disease, — usually called hypochondriasis. 
Pantaphobia, fear of everything. Phobophobia, fear of being 
afraid. Mysophobia, fear of contamination. 

As illustrating imperative conceptions, a few cases from ray 
own experience may be cited. A very strong shoemaker, past 
middle life, was oppressed with the idea that he could not walk 
unless he had some covering over his head. On a stormy day 



DISTURBANCES OF INTELLECTION. 435 

the natural cloud-canopy sufficed, and on a clear day an umbrella 
carried over his head gave a measure of relief, so that he was 
able to command his movements. He could walk in a thick 
wood, but, as he himself said, if ten feet of clear sky intervened 
between the wood and a spring he would die of thirst before he 
could cross over. 'No other symptom of physical or mental ail- 
ment could be detected. 

A lady had a dread of personal defilement : hundreds of times 
daily she washed her hands, without avail ; bank-notes fresh from 
the press were the only money she would use ; a door-knob she 
would never touch, but would remain in the room until some one 
opened the door ; in putting on her clothes only the inside of each 
piece was touched by her fingers, and this as daintily as possible. 
Without entering into further details, suffice it to state that her 
whole life was arranged in order to avoid as much as possible 
contact with any person or thing. On my asking her to shake 
hands her embarrassment was extreme : though naturally polite, 
and feeling under some obligation to me, she was nevertheless 
entirely dominated by her imperative conception. Finally she 
said, '^ Dear doctor, don^t ask me : you know you touch so many 
people.^^ 

A gentleman entirely rational, able to manage his business 
affairs well and to converse on all subjects, was completely ruled 
by imperative conceptions and morbid impulses, the connection 
and the independence of which are well illustrated by his case. 
Thus, for many years he had an impulse continually to rub his 
arms against his sides, and this he did incessantly until coat after 
coat was rubbed into holes. No morbid conception could be 
found underlying this or some of the other impulses which he 
had. Nevertheless, he did have imperative conceptions with 
outgrowing secondary impulses. For many months he was 
markedly mysophobic. Then he had the conception that he must 
lay things down straight and could not do it. Most of his waking 
moments were at this time spent in putting down and arranging. 
When he placed a book on the table, over and over and over 
again he would lift it up, straighten it, pick it up and re-lay it, etc. 
Often at night he would be two or three hours getting away from 
his coat, which he was perpetually arranging upon the chair on 
which he had laid it. There was no delusion, and on my asking 



436 DIAGNOSTIC NEUROLOGY. 

the man why he yielded to the impulse, he said, ^^I can resist it 
for a while, but after a time the same overpowering sensation comes 
as when I hold my breath, and I must do it. I have found that 
if I say very fast, ' It is straight, it is straight,' over and over 
again, at the same time cracking my fingers briskly by shaking 
my hand, the impulse often suddenly vanishes, with immediate 
relief." 

The relation of imperative conceptions and morbid impulses to 
insanity is a matter of great theoretical and practical interest. 
They are undoubtedly frequent in the insane, and usually careful 
examination of a case in which they are present will reveal dis- 
tinct symptoms of alienation. They may, however, exist in 
persons whose intellectual actions are in other respects entirely 
normal, and in whom the judgment is not dominated by the 
conception which may influence the actions against the judgment. 
To himself the sane subject of an imperative conception seems 
possessed by a demon whom he must obey. 

The relation of morbid conceptions and impulses to legal 
responsibility for acts committed involves questions of great 
practical difficulty. The victim of the morbid impulse cannot 
properly urge such impulses as excuses unless the deed in ques- 
tion is immediately produced by them. When the act is com- 
mitted because the actor is forced to do it by a morbid impulse, 
the actor is, of course, morally blameless ; but who can tell whether 
the impulse was resisted to the uttermost ? Moreover, the needs 
of society, and the ease with which such impulses could be alleged 
or counterfeited, very properly give us pause in attempting by them 
to excuse a criminal act. The clearest possible proof should be re- 
quired that the impulse was really morbid and irresistible. 

Names have been given to various morbid impulses. In most 
cases these names are misleading in their etymology and primary 
meaning. They usually end in " mania ;'' but the morbid impulse 
is not a mania, but a symptom which may either coexist with ma- 
niacal manifestations or be isolated. Thus, pyromania is a morbid 
impulse to set fire to buildings; kleptomania, a morbid impulse to 
steal ; homicidal mania, a morbid impulse to kill ; suicidal mania, 
a morbid impulse to commit suicide, etc. Unfortunately, the 
nomenclature is made still more complicated by the fact that 
often when the morbid impulse exists in an insanity the name 



DISTURBANCES OF INTELLECTION. 437 

usually applied to the impulse is given to the whole attack. 
Thus, a melancholia with an impulse to set fire to houses would 
be called pyromania. Not rarely, indeed, there is not even the 
excuse of the existence of a morbid impulse for the name given 
to the disease. Thus, the man who, not believing in a future 
existence, commits suicide because he is suffering from the un- 
utterable misery of melancholia, is logical and reasonable in his 
suicide, and does not kill himself through any morbid — i.e., un- 
reasoning — impulse. Suicidal and homicidal maniacs are simply 
persons who have a tendency to kill themselves or others. 

Morbid desires are exaggerations or perversions of natural ap- 
petites, and are chiefly seen in regard to hunger and the sexual 
passion. Mere depravity and wickedness may convert man into 
a monster : neither cannibalism nor the lowest sexual degradation 
is necessarily the offspring of disease. Nevertheless, disease may 
affect the appetite for food or for sexual congress as it does other 
functions of the nervous system. 

In mania, in paretic dementia, in hysteria, indeed, in almost 
any form of insanity with excitement and exaltation, the sexual 
passion may become an all-devouring, insatiable lust. In the 
female this condition is known as nymphomania; in the male, 
as satyriasis. The victim of it talks incessantly and indecently 
about sexual congress, makes furious love to all persons of the 
opposite sex, exposes the person, etc. Erotomania is a very fre- 
quent condition, in which there is the appearance but not the reality 
of sexual excitement. The subject of it conceives a strong attach- 
ment for some person of the opposite sex whom perhaps he or 
she has never seen, and lives in a perpetual worship. Sometimes 
the object is in public life, and is followed from place to place 
with a pertinacity and publicity which may amount to actual 
persecution. Even if opportunity offer, the erotomaniac makes no 
effort at cohabitation. Satyriasis leads to sexual excess and to 
rape. Erotomania is a platonic affection, which involves the 
higher conceptive sphere rather than the lower nerve-centres, and 
leads to sexual abstinence. 

The individual symptoms or manifestations of disordered men- 
tal action having been sufficiently discussed, the consideration of 
the so-called mental diseases is in order. Before, however, enter- 
ing upon the subject of insanity it is necessary to discuss the pro- 



438 DIAGNOSTIC NEUROLOGY. 

found active disorder of intellection connected with constitutional 
affections to which the name delirium is given. 

By the term delirium is meant an acute mental condition in 
which there is incessant, more or less incoherent talk, which is 
not directly inspired by surrounding objects, — the sufferer being 
so occupied with his own mental conceptions that he is not entirely 
conscious of his situation : indeed, in most cases there is not 
a true consciousness. Delirium may be either low in type, or 
wild and furious. It is produced by a large number of diseases 
which are not immediately connected with the nervous system : 
under these circumstances the cause of the mental aberration is to 
be made out by diagnosing the disease which produces it. It is 
a general law, with few exceptions, that a delirium which is low 
and muttering, if acute, and not preceded by protracted evidences 
of cerebral disease, is due to some affection not immediately con- 
nected with the brain. Violent acute delirium is often the result 
of brain-disease, but may be secondary. In pneumonia occurring 
in persons exhausted by dissipation a wild delirium may be the 
most prominent symptom, and give rise to the false diagnosis of 
phrenitis. In every case of sudden severe delirium the lungs 
should be carefully examined, when the physical signs may de- 
monstrate a pneumonia, although there may be neither cough, 
pulmonic distress, nor apparent disturbance of the respirations. 

A sudden severe delirium may mark also the onset of an acute 
general disease, such as malarial fever, scarlet fever, etc. Usually 
in such a case the delirium itself is low and muttering; but, even 
if it be fierce, the pulse is weak and feeble, the countenance is de- 
pressed, and a general expression of vital failure exists, which to 
the experienced eye at once indicates the presence of a depressing 
poison in the blood. 

Before entering upon the discussion of the classifications of 
insanity, the question how much of abnormal mental action is 
compatible with sanity seems naturally to present itself. Its 
answer involves the definition of the words sanity and insanity, 
and, like these definitions, probably will always be unsatisfactory. 
Insanity is not a definite disease, but an abnormal state, varying 
indefinitely in its intensity, — separated by no tangible line from 
sanity, — arising from a number of diverse diseases, and termi- 



DISTUKBANCES OF INTELLECTION. 439 

Dating in most various ways. It is a mental weakness ; and it 
would be as absurd to ask for a definite line separating the phys- 
ically weak from the physically strong as to ask for one separating 
the mentally w^eak from the mentally strong. 

For his own purposes of science, or even of treatment, the 
physician needs no definition of insanity, but the relations of man 
to man are so altered by insanity that the law must take par- 
ticular notice of the subject of insanity. Even, however, for the 
purposes of the law insanity is not a fixed term, because it is a 
well-assured axiom that a man may be legally sane — i,e,, respon- 
sible — for one class of acts, and insane — i.e., irresponsible — for 
another class of acts. 

As already contended, there can be no scientific definition of 
insanity except that it is a state of mental aberration. Such a 
definition does not meet the needs of the court-room, which de- 
mand an arbitrary although shifting line between the sane and 
the insane. The term insanity as used by judges and lawyers is 
legal rather than scientific, and the law ought clearly to define 
the word. It does, however, no such thing. It does not frame 
an authoritative definition of insanity, but through the mouths of 
its exponents puts forth an abundance of contradiction. 

Probably as good a definition of insanity as the expert can 
frame to meet the clamor of lawyers is, that insanity is a con- 
dition of mental aberration sufficiently intense to overthrow the 
normal relations of the individual to his own thoughts and acts, 
so that he is no longer able to control them through the will. 
The diflBculty of applying this definition to the individual case 
consists in the fact that the will does not all at once lose its grasp 
on the lower faculties, but that little by little these slip from 
under its control. Of degrees of responsibility none but the All- 
knowing can judge, and to say with assured correctness just when 
the lost control has been lost is not given to mortals. In a court 
of justice it becomes the expert to state as nearly as may be the 
exact mental condition of the prisoner, leaving to the judge the 
decision as to the legal responsibility of the prisoner, — i.e., the 
relation of his mental condition to the law of the commonwealth 
in which the trial is held. 

Insanity being a symptomatic condition, and not a disease, it is 



440 DIAGNOSTIC NEUROLOGY. 

illogical to consider different forms of it as distinct diseases : the 
best that can be done is to describe the diseases of the brain and 
the insanities which accompany them so ^ far as we know such 
diseases, and, when our knowledge of diseases fails, to describe 
forms of insanity not as diseases but as symptom-groups. 

The purposes of discussion necessitate the naming of these 
symptom-groups, for it becomes essential to have short terms 
which shall convey a whole group of symptoms at once to the 
mind. Naming symptom-groups naturally leads to the delusion 
that these groups are diseases : hence melancholia, mania, etc., 
are constantly written about as though they were terms of equiv- 
alent force to typhoid fever or scarlatina, whereas they are simply 
of the same rank as diarrhoea or paralysis. 

This is shown by the following facts : 

1st. Similar mental symptoms may be produced by various 
organic brain-diseases ; or, as Dr. Charles F. Folsom says {Amer- 
ican System of Practical Medicine, vol. v. p. 202), "tumors, new 
growths of all kinds, exostoses, spicules or portions of depressed 
bone, embolisms, hemorrhages, wounds, injuries, cysticerci, may 
give rise to any of the symptoms of the various psycho-neuroses 
and cerebro-psychoses." 

2d. Almost any form of insanity may exist without demonstra- 
ble organic lesion. This is shown by the well-known fact that in 
a large number of autopsies upon the insane skilled observers 
have failed to detect alteration of brain-structure. 

3d. Antagonistic forms of insanity may be produced by lesions 
which are, so far as we can perceive, identical : as is witnessed 
by the circumstance that in paretic dementia the usual expansive 
delusions may be replaced by a profound melancholy. Further, 
lesions usually accompanied by insanity may exist without mental 
disorder. Dr. Folsom says, " Indeed, nearly every pathological 
condition of the brain known in insanity — in kind, if not in ex- 
tent and degree — may be found in diseased or injured brains 
where there has been no mental disease in consequence.'^ 

4th. The form of the insanity may change in the individual 
without appreciable cause and without conceivable change of dis- 
ease. 

5th. Almost every grade of case exists in nature, uniting by 
an unbroken series the various insane-symptom groups. Thus, 



DISTURBANCES OF INTELLECTION. 441 

of the two most antagonistic forms of acute insanity, acute 
mania and acute melancholia, Bucknill and Tuke say (Phila. 
edition, 1874, p. 427), " Between acute mania and acute melan- 
cholia no distinct line of demarcation can be drawn. The 
domains of the two diseases overlap so much that, in practice, 
cases not infrequently present themselves which may with equal 
propriety be referred to one or the other/^ 

The considerations which have been brought forward show 
that the various forms of insanity are not entitled to be con- 
sidered as distinct diseases, and that at present we cannot connect 
cerebral lesion and mental symptoms in their causal relations. 
More than this, the rapid recoveries which sometimes occur in 
apparently hopeless cases of insanity show that the symptoms 
cannot depend upon alterations of the brain-substance suflBciently 
gross to be detected by our present methods. 

I shall narrate, as showing this, a single case, that of a lady 
with whom I was thrown in almost daily contact for many 
years. At about the age of forty-five she was taken with re- 
ligious melancholia of the most pronounced character, which 
was accompanied by agitation, and sometimes by frenzy. This 
persisted for fifteen years. There had been in all this time not 
the slightest wavering of the mind of the woman in regard to 
her future life. She firmly believed that her soul was irretriev- 
ably lost. At the same time her general emotional nature had 
undergone a retrograde change : she had become exceedingly jeal- 
ous of attentions paid to other persons, and had lost many of 
the peculiar traits of refinement w^hich had been her especial charac- 
teristic. After being in an asylum for some time, she recovered 
intellectual power sufficient to enable her to take charge nominally 
of her husband^s house, which was really managed by her at- 
tendant, but there was no wavering in her delusion, nor even any 
temporary abatement of her misery. 

One night the attendant noticed this lady on her knees at 
the bedside. This was the first time in fifteen years that she 
had been known to kneel in prayer. The nurse, being a wise 
woman, did not disturb her, and there she remained all night. 
In the morning she joined the family, and said that she had 
found Christ, and that she was perfectly well and happy. Her 
old disposition had returned, and her peculiar jealous sensi- 



442 DIAGNOSTIC NEUROLOGY. 

tiveness had disappeared. The woman who had been buried for 
fifteen years had emerged in one night without even the grave- 
clothes about her. This continued for one week. Then the old 
cloud came on her, and for days she was in the old condition ; 
but suddenly the sunlight again broke through the clouds, and 
she remained well for three or four days, to relapse, and after 
some hours again to regain her sanity. These attacks continued 
to recur at gradually lengthening intervals. Finally she had 
been perfectly sane for several consecutive months, when suddenly 
she was seized with a serous diarrhoea, causeless as far as could 
be ascertained, and hopeless as far as relief by remedies was con- 
cerned. In forty-eight hours she was dead. I believe that the 
cause of that death was the same obscure something w^hich had 
so potently aifected for years the emotional life : that which for 
so many years had dominated the nerve-centres of higher life 
attacked and paralyzed the lower centres of animal life, and death 
came speedily. 

We can scarcely conceive the nature of a lesion which, after 
having held for fifteen years the nerve-centres in an iron grip, 
suddenly let go its hold. For its demonstration the microscope 
is useless. Our best instruments show us in human spermatozoa 
nothing but irregular, transparent specks of protoplasm, not to 
be distinguished one from the other. Yet the records of past gen- 
erations are written in the little formless particles, in which also 
are enfolded the potentialities of future successions of men. Struc- 
ture and function seem so widely independent that it is almost 
hopeless to expect that we shall ever understand the infinitely 
delicate changes which take place in the complex protoplasm of 
the brain, and to be able to say why waves of emotional and 
mental paralysis sweep over the individual. I believe that the 
changes are physical, but I also believe that it will never be within 
human power to recognize their nature. The microscope is a 
coarse, blundering tool, powerless to reveal the ultimate changes 
of nervous protoplasm gone mad. 

Almost every systematic writer upon the subject has his own 
private classification of insanity, — a fact which is strong evidence 
that no classification as yet made, or as yet possible to be made, is 
scientifically accurate. Much of the confusion arises out of the 
false view that the so-called distinct insanities are distinct diseases. 



DISTURBANCES OF INTELLECTION. 443 

If it were once generally acknowledged that almost all of these 
forms of insanity in nature shade into one another^ and that the 
separations are arbitrary, simply made for convenience of study 
and discussion, the simplest arrangement would become popular 
because the most convenient. The following arrangement is more 
simple than novel, and better adapted to the need of the practical 
alienist and student than to that of the theorizer. 

Group L — Complicating insanities, in which there are distinct 
physical symptoms of disease of the brain, the cerebral disorder 
not being due to an acquired or inherited constitutional diathesis. 

Gh^oup IL — Constitutional insanities, in which the cerebral dis- 
order is due to an acquired or inherited constitutional vice, in- 
cluding in the latter term diathesis, constitutional diseases, and 
subacute and chronic poisonings involving wide-spread areas of 
the body. 

Group III, — Pure insanities, in which the mental disorder is 
not accompanied by essential symptoms of organic brain-disease 
or dependent upon a diathesis. 

COMPLICATING INSANITIES. 

Almost any form of organic brain-disease, such as abscess or 
tumor, may be accompanied by mental disorder. If the gross 
lesion be focal, it gives rise to focal symptoms, by which its exist- 
ence is betrayed. In other words, the character of a focal lesion 
in complicating insanities is to be made out by a study of the 
purely physical symptoms, it being borne in mind that pro- 
found mental aberration of a chronic type, and not accompanied 
by stupor, indicates a wide-spread cortical lesion rather than a 
focal disease. The cortical lesion may, however, be secondary to 
a focal disease. 

The only wide-spread brain-diseases which produce Complicating 
Insanities are Meningitis, acute and chronic, and Periencephalitis, 
acute and chronic. 

Meningitis. — Acute meningitis is very rare in the adult, but 
may be the result of a sunstroke or of a traumatism. It is usu- 
ally secondary to a chronic meningitis, a brain-abscess, or other 
organic cerebral affections. If, as is very rarely the case, the 
chronic disease has been obscured and perhaps altogether over- 



444 DIAGNOSTIC NEUROLOGY. 

looked, a secondary meningitis may appear to be a primary affec- 
tion. This I have especially seen in cerebral syphilis, when the 
original gummatous tumor has probably been very limited in 
its extent. It is probable that an acute meningitis may be pro- 
duced directly by septic poisoning. 

The symptoms of an acute meningitis are furious delirium, 
with wild outcries, great restlessness, perpetual fighting, and often 
convulsions, the attack being preceded by an agonizing headache, 
which persists as long as consciousness is retained. There is always 
in the beginning pronounced fever and excitement of the circu- 
lation, which is revealed by a rapid, bounding pulse, or by one 
which is small and very hard, — i. 6., the " corded pulse." The 
disease is often ushered in by a rigor, vomiting is frequent, and 
violent epileptiform convulsions may mark the abrupt onset. The 
headache and mental excitement are intensified by bright lights 
or loud sounds. The convulsions may be partial, and in mild 
cases the motor disturbance may be manifested by persistent 
muscular rigidity, which, when the base of the brain is chiefly 
affected, is most marked in the neck. The stage of excitement 
lasts from a few hours to several days, and is followed by one of 
paralysis and depression, in which there is stupor deepening into 
coma, a slow, intermittent pulse, or other evidence of failing cir- 
culation, and finally death amidst wild convulsions, or, it may be, 
in profound muscular relaxation. 

The meningitis of which I have so far been speaking is the 
sthenic disease as it occurs during adult life. In childhood in- 
flammation of the brain-membranes is comparatively frequent, 
but in the great majority of cases it is due to the presence of 
tubercles in the pia mater. In the child suffering from menin- 
gitis delirium is usually not so marked a symptom as is stupor 
or coma. This is owing partly to the impressible nature of the 
cerebral cells during early life, which leads them to be over- 
whelmed by an irritation which would in the adult produce only 
an active delirium, and partly to the tendency to the outpouring 
of serous exudation into the cerebrum being much greater in youth 
than in age. 

For the purpose of diagnosis it is better to study first the com- 
monest form of meningitis in childhood, — i.e., tubercular menin- 



DISTURBANCES OF INTELLECTION. 445 

gitis. Before doing so, the tubercular affection as it occurs in 
adults requires some consideration. 

Except in very rare cases, tubercular meningitis in the adult is 
secondary, developed as the result of a tubercular infection pro- 
duced hy tubercular or caseous degeneration of the lung or other 
distant organ, or coming on during convalescence from typhoid 
fever or other acute systemic affection. It may develop suddenly 
with violent psychical disturbances, which may continue for a 
few hours or days and then be lost in coma. The first marked 
symptom may be furious maniacal outbreaks, happening only at 
night, the patient during the day being entirely rational and free 
from any pronounced symptoms of cerebral disease. 

Occasionally the tubercular deposit is so localized that the 
earlier symptoms are those of a focal lesion. Thus, cases have 
been recorded in which an aphasia was the first evidence of the 
disease ; and a local spasm, or even local paralysis, or a sudden 
Jacksonian epileptic attack, may usher in the disease. In typical 
cases the attack begins with a headache, which may be very severe, 
and may be accompanied by marked anxiety, depression of spirits, 
and often psychical symptoms resembling those of insanity, such as 
hallucinations, melancholia, or a mild mania. The motor symp- 
toms usually follow rapidly upon the other evidences of cerebral 
disturbances. General or local convulsions are rare, but various 
forms of paralysis are frequent ; the palsy may affect one arm or 
one leg, or take the form of a hemiplegia ; under these circum- 
stances it is rarely, if ever, complete. Ptosis, strabismus, dilata- 
tion or contraction of the pupil, facial palsy, or other losses of 
power about the face are very frequent, on account of the tendency 
of the tubercular exudation to mass itself about the base of the 
brain. Fever is usually a pronounced symptom, and may be 
irregular or may have a diurnal rhythm similar to that of typhoid 
fever. The abdomen is usually retracted, and constipation pro- 
nounced. Vomiting is often, but not invariably, present. If 
there be local disease of the alimentary canal, severe diarrhoea 
may entirely mask the other abdominal symptoms. Whenever 
in a case of phthisis, or during the convalescence from an acute 
constitutional disorder, symptoms of irregular cerebral disturb- 
ance develop, the physician should always suspect the occurrence 
of a tubercular meningitis. The symptoms of the disorder vary 



446 DIAGNOSTIC NEUROLOGY. 

greatly, and the diagnosis is justified whenever in the presence 
of the exciting cause organic brain-disease is indicated by the oc- 
currence of headache, marked psychical disturbance, or local palsy, 
provided no other explanation of the symptoms can be made out. 
The symptoms of a typical case of tubercular meningitis occur- 
ring in childhood may well be arranged in three stages besides the 
prodromic period. It must be borne in mind that this division is 
arbitrary, and that the stages insensibly pass into one another in 
any individual case ; also that in some cases one or more of these 
stages are absent, and that in other instances the symptoms are so 
mixed together that none of the stages can be clearly made out. 
The first period is prodromic. The child's health begins to fail 
mysteriously; its disposition alters so that it becomes peevish and 
especially irritable; its sleep at night is broken, sometimes deliri- 
ous, sometimes interrupted by night-terrors ; the appetite fails, the 
bowels are constipated, and vomiting may occur: at the same time 
there is a feverishness rather than a distinct fever. This prodro- 
mic condition lasts for about a week, when the child enters the first 
stage of the developed affection. The symptoms of this stage are 
as follows: headache, which may not be severe, but which is com- 
monly by older children bitterly complained of, or in young chil- 
dren is manifested by a peculiar plaintive cry, occurring at irregular 
intervals, and often breaking out in the midst of a restless night- 
slumber, although rarely heard after the coma has been fully 
developed, and so characteristic as to be known as the hydro- 
cephalic cry ; vomiting, which may occur only at long intervals, 
or may be incessant and associated with nausea, and which is very 
frequently produced by changes of position ; constipation, with 
retraction of the belly, — a symptom which, however, may be 
entirely masked if there be tubercular or other irritation of the 
intestines or their glands ; a condition of the pulse which is not 
in accord with the extent of the fever, and may be distinctly 
slow and even somewhat irregular; spasmodic contraction of the 
muscles of the neck, causing some retraction of the occiput and a 
perceptible stiffness of the neck when the head is raised from the 
pillows; fever, which has nothing characteristic about it, but is 
rarely severe. General or local convulsions may occur, and the 
pupil may be implicated. When, however, pupillary symptoms 
become marked, and the evidences of paralysis appear about the 



DISTURBANCES OF INTELLECTION. 447 

eye and face^ the child may be considered to have entered into the 
second stage of the disorder. 

Stupor^ coma, and muscular relaxation are the most pronounced 
symptoms of the second stage. The pupils are dilated or con- 
tracted, sluggish in their movements, or altogether fixed ; strabis- 
mus, distortion of the face, failure of the power of articulation, 
or other evidences of loss of power in the muscles about the 
head, may show that one or more of the nerves at the base of the 
brain are suffering from the pressure of the exudation. Head- 
ache, vomiting, and constipation may continue. The pulse is usu- 
ally slow and intermittent or otherwise irregular. Various con- 
tractures may be present; convulsions or convulsive movements 
of the extremities are frequent; the rigidity of the neck persists; 
and the hydrocephalic cry indicates that in the midst of the 
stupor the little patient is still sensible of his sufferings. As 
this stage progresses, the stupor deepens, until the child no 
longer exerts any control over the bladder or rectum and cannot 
be aroused. Gradually as the coma becomes more pronounced 
the final paralysis is reached, and often the rigidity of the neck 
and the retraction of the belly disappear amidst the universal 
muscular resolution. The pulse becomes rapid, feeble, and irreg- 
ular; the temperature may become subnormal, or it may rise 
very high, or it may rise and fall without regularity or order 
until at last death ends all. 

The symptoms of the prodromic stage of tubercular meningitis 
are sufficient to excite suspicion, but rarely do they warrant a 
positive diagnosis. If the case has developed in an ordinary 
manner, and especially if there is in the medical history of the 
child^s family a distinct tubercular taint, the character of the dis- 
ease is usually apparent by the time the first stage of the disorder 
is fairly entered into. 

In irregular cases the diagnosis is not so easy. The prodromic 
stage may be slight, and there seems indeed to be a form of the 
disease in which the attack is said to be ushered in by convul- 
sions. There is said to occur in young children an idiopathic 
meningitis or leptomeningitis, the diagnosis between which and 
tubercular meningitis may be attended with much difficulty. The 
idiopathic affection more frequently than the tubercular disorder 
begins abruptly with furious convulsions, but for several days 



448 DIAGNOSTIC NEUROLOGY. 

before this outbreak there may be headache, restlessness, sleepless- 
ness, or delirium at night, change in the disposition, vomiting, 
constipation, contracted pupils, with excessive sensitiveness to light 
and sound, or other hyperaesthesia, vertigo, and other symptoms 
closely resembling those of the prodromic period of the tubercular 
disease. 

During the convulsions of idiopathic meningitis the child is 
entirely unconscious : spasm of the glottis, as indicated by long- 
drawn, crowing inspiration and impeded expiration, is not rare. 
Either through it or through cramp-arrest of the respiration 
cyanosis may be induced and death occur during the first series of 
convulsions. Paroxysms of convulsions may succeed one another 
at short intervals for many hours, or may subside, when stupor 
or coma, ocular and facial paralysis, loss of sight and hearing, 
and progressively increasing muscular relaxation, with or' without 
contractures, indicate the constantly-increasing pressure from ex- 
udation into the membranes and ventricles of the brain. 

Since tubercular meningitis almost of necessity ends in death, 
whilst in non-tubercular meningitis the child has a chance of re- 
covery, great interest attaches to the diagnosis between the two 
affections. Unfortunately, there are no symptoms which are pa- 
thognomonic of either disease. The existence of a known heredi- 
tary taint renders the diagnosis of tubercular meningitis probable; 
its absence favors the hope that the attack is not tubercular. A 
prolonged prodromic period indicates a tubercular aifection ; and 
yet I have seen three cases in which the symptoms seemed to 
warrant the diagnosis of a hopeless tubercular meningititis, but in 
which the patients recovered. 

In one of these cases the father was a very dissipated man, and 
sufficient ground was afforded to warrant the suspicion that the 
meningitis was due to inherited syphilis. The second case occurred 
in an orphan fourteen years of age, of no known family history, 
but did not present any other symptoms of syphilis than those of 
a slow, progressive basilar meningitis. Recovery under the use 
of iodide of potassium was, however, complete. 

In the third case, occurring in a child whose joints and ribs 
indicated a rachitic tendency, syphilitic taint was absolutely denied 
by both parents. There was, however, a history of possible trau- 
matism, and the symptoms were chiefly furious repeated convul- 



DISTURBANCES OF INTELLECTION. 449 

sions, with some rigidity of the base of the neck, rapid loss of 
flesh, and headache. Recovery took place under proper hygienic 
measures and the use of iodide, phosphates, etc., the iodide of 
potassium seeming to achieve most of the result. 

Cerebro-spinal meningitis attacking a young child may produce 
symptoms which are not to be distinguished from those attributed 
to a fulminating idiopathic meningitis, and it is probable that cases 
supposed to have been idiopathic have really been instances of 
the epidemic disease. Moreover, pneumonia may produce symp- 
toms closely resembling those of a true meningitis : even in the 
adult the cerebral symptoms of a pneumonia may completely 
mask the pulmonic disturbance, and Grisolle, as quoted by Prof. 
Loomis, affirms that the usual physical signs may be altogether 
wanting. I have seen a number of cases in which the sole 
distinct symptomatic evidence of pneumonia was acceleration of 
the breathing, noticeable only when carefully looked for, and in 
which no crepitant rale could be heard at any time during the 
disease. Absence of vesicular murmur or presence of bronchial 
breathing, however, usually betrays the pulmonic lesion. Possibly 
bronchial breathing may in some cases be wanting, and even a 
transmitted vesicular murmur be heard ; but I can scarcely con- 
ceive that percussion -dulness can be absent in the pneumonic con- 
solidation of the adult. In young children I have seen headache, 
strabismus, convulsions, intense persistent rigidity of the neck, 
with fever and a slight occasional barking cough, followed by 
death on the sixth day, and at the post-mortem have found exten- 
sive pneumonia, with simple hyperaemia of the brain-membranes 
and an excess of serous fluid in the brain, the microscope showing 
that there had been no out-wandering of blood-corpuscles and no 
purulent or fibrinous exudation. In this case the only physical 
sign that could be detected was a relative dulness over the affected 
lung. The percussion-note was distinct and clear, but not quite so 
clear as over the opposite lung. In such a case as this the lung- 
affection might very easily be overlooked. The intensity of the 
fever is, however, much greater than in either meningitis or cere- 
bro-spinal meningitis, and is especially out of proportion to the 
severity of the meningeal symptoms; the breathing is also ex- 
cessively accelerated. Meningitis, generally of the vault, is a not 
very infrequent complication of pneumonia, but there is no way of 

29 



450 DIAGNOSTIC NEUROLOGY. 

distinguishing between meningitis and meningeal irritation in the 
pneumonia of childhood. The practical points are that in these 
cases the pneumonia is the primary affection, to which the treat- 
ment is to be especially directed, and that, whenever symptoms 
of fulminating meningitis appear in children or very old people, 
the lungs should be carefully examined, especially in their apical 
lobes, which are usually, but not always, the part affected in the 
so-called cerebral pneumonia. 

Acute Periencephalitis, — Acute Peripheral Encephalitis, 
Phrenitis, Mania Gravis, Typhomania, Acute Delirium, Delirium 
Grave, Bell's Disease (Luther Bell). — This affection sometimes 
follows intense emotional excitement, sometimes appears as the 
result of a prolonged strain upon the nervous system, such as 
occurs during a business crisis, and sometimes develops without 
apparent cause. It is more frequent in females than in males, 
and especially occurs in cases of seduced pregnant women. 

The symptoms may come on with extreme suddenness, or 
may be preceded by prodromic evidences of cerebral disturbance. 
These prodromes in rare cases take the form of increase of men- 
tal power, in others of brief nocturnal attacks of wandering de- 
lirious restlessness; or there may be short periods of impaired 
consciousness, especially upon waking in the morning, or, as in 
one of my cases, even an epileptiform convulsion. The fully- 
developed disorder naturally divides itself into two stages, — first, 
that of acute maniacal delirium, and, second, that of apathy and 
collapse, with coma. The delirium is always of an excited type, 
accompanied by violent incoherent speech, and usually by a fury 
of fighting and of destructiveness. 

Hallucinations and half-formed delusions are present, and often 
bear a close relation to the cause of the attack. The abandoned 
mistress will in her ravings recount her past shame and present 
agony. The business-man Avill be perpetually occupied with an in- 
coherent jumble of business transactions. Almost invariably along 
with the delirium there is great physical restlessness, which grows 
more intense until it causes the patient to leap from his bed and to 
attempt to run away. Very commdnly violent assaults are made 
upon the attendants. Convulsions are not common. In many 
cases the delirium is at first not continuous, occurring only at 
night, or is at least interrupted by brief intervals of comparative 



I 



DISTURBANCES OF INTELLECTION. 451 

rationality during the daytime. Finally, however, there is per- 
sistent intense mania. In one of my own cases the patient, during 

the day, told his wife that she must protect herself from him 

that he loved her most fondly, but that he was going into a con- 
dition of insanity, in which he would certainly kill her. From 
this time until his death he was furiously maniacal durincr the 
night, although for several days he would recognize his friends 
during the daytime, and for a moment or two talk rationally. 
There is usually absolute insomnia. The pulse is rapid, and even 
if in the beginning it possesses a show of force, it is really soft 
and compressible. There is no desire for food, and generally an 
absolute refusal to take it. There is also distinct fever, the tem- 
perature rising sometimes to 106^ F. According to my obser- 
vation, the temperature varies with a stormy irregularity w^hich 
is almost characteristic, rising and falling many degrees many 
times during the twenty-four hours. Its variations are con- 
nected with the mental and physical excitement of the patient, — 
maniacal outbursts producing an immediate rise of the tempera- 
ture. The pupils may be contracted, dilated, or normal. In the 
course of a few hours to several days the second stage of the dis- 
order develops. There is now quiet, with coma or else mutter- 
ing delirious unconsciousness, failing pulse, cool skin, and general 
evidences of collapse. In the early part of this stage, when 
aroused the patient may respond incoherently, or perhaps give 
some slight evidences of comprehending what is said to him, 
but rapidly sinks low^er and lower until he dies from exhaustion. 
Early in the disorder the skin becomes very harsh, and finally cya- 
notic; in the later stages irregular desquamation, or even ulcer- 
ation, may occur. In a case quoted by Spitzka the anaesthesia was 
so complete that the patient gnawed off a portion of one of his 
fingers. Pemphigus-like vesicles, phlegmons, gangrenous patches 
of skin, or gangrenous extremities, not rarely appear, but are fre- 
quently absent, and are not characteristic. Complete recovery 
never takes place, although it is affirmed that in rare cases the 
patient is restored to a fair degree of physical health with only a 
slight mental defect. Usually the end is death ; sometimes per- 
manent complete dementia and more or less wide-spread paralysis 
result. After death evidences of peripheral encephalitis are to 
be found. 



452 DIAGNOSTIC NEUROLOGY. 

This disease is very closely related to acute mania : indeed, 
unless it be by the presence of marked fever, and by the intensity 
of the symptoms, I do not see how the affection is to be separated 
from acute mania. If it be correct, as is asserted by Hammond 
(^Treatise on Insanity^ p. 546), that the temperature is never ele- 
vated in acute mania, then it is possible to diagnose between acute 
mania and peripheral encephalitis. Folsom, however, affirms that 
in acute mania the skin is hot; and at present we are not able to 
state positively that attacks of acute mania are other than cases 
of peripheral encephalitis of a mild type. (See Acute Mania, p. 
471.) 

General Paralysis of the Insane — Paretic Dementia, Perien- 
cephalitis, General Paralysis of the Insane, Paresis — is a disease in 
which the lesion is a progressive inflammatory alteration of the 
brain-cortex, which registers itself symptomatically in the motor, 
sensory, and mental spheres of action. 

Cases of paretic dementia are divisible, so far as their mental 
symptoms are concerned, into four varieties ; but it must be remem- 
bered that this division is an arbitrary one, and that wliilst abun- 
dant cases exist in nature corresponding accurately to one or other 
of the classes, yet every grade of case exists between the classes, 
and the march of the mental malady sometimes is so irregular 
that in one portion of its course the individual case might be 
assigned correctly to one variety of the disease, but at another 
time would belong to another variety. 

In the first form of paretic dementia are included those cases in 
which progressive failure of power constitutes almost the whole 
mental disturbance, the mental faculties consentaneously growing 
less and less until the patient becomes childish, and at last com- 
pletely demented, without emotional disturbance or delusions 
having been present. (It is these cases especially that are popu- 
larly spoken of as softening of the' brain.) 

The second variety of paretic dementia is that in which delu- 
sions of grandeur or expansive delirium are present. The character 
of these delusions has already been sufficiently pointed out. (See 
page 431.) It is essential to remember that these delusii^ns may 
exist in so mild a degree that they may be very readily over- 
looked. Further, in many cases they are replaced by a bien-etre 
which may be looked upon as a condition of undeveloped delu- 



DISTURBANCES OF INTEJLLECTIOX. 453 

sion. Thus, the man sunk in the deepest poverty will be exces- 
sively happy and jolly, misfortunes having no power to depress 
him, although he makes no assertion of the possession of great 
power or wealth. In all cases of the present variety of general 
paralysis there is progressive mental failure, and it is, therefore, 
evident that the cases in which a simple bien-etre exists may be 
looked upon as midway between the first and the second variety 
of the disease. 

Maniacal outbursts may occur in any variety of general paraly- 
sis, but they are more common and more frequent when there are 
delusions of grandeur. 

The third form of general paralysis is that in which there is 
emotional depression, and even pronounced melancholia, w^ith de- 
pressive delusions. Not rarely the depressive delusion relates to 
the person of the patient, who believes himself ill, deformed, or 
wanting in some member or function. In this way arises the so- 
called hypochondriacal variety of general paralysis. 

The fourth form of general paralysis is that described by Dr. 
Fabre, in which excitement and depression alternate so as to make 
a periodic or circular insanity. The existence of this variety has 
been confirmed by Dr. W. Julius Mickle {General Paralysis, 
London, 1880), who further says that when there are only two 
phases these succeed each other suddenly, but that in some cases 
there are three periods, — (1) excitement, (2) calm, (3) depression, 
— in this differing, therefore, from non-paralytic circular insanity, 
in which the usual order is (1) excitement, (2) depression, (3) 
quietude or lucidity. 

The physical symptoms of paretic dementia are chiefly con- 
nected with the motor function, although late in the disorder sen- 
sation is also impaired, and may be almost abolished. Except in 
regard to the epileptic attacks (see page 116), the motor symptoms 
are always paralytic, and are especially characterized by their in- 
completeness and by their connection with tremors and loss of 
control over muscular movements. In the earliest stages of the 
disorder the loss of control over complicated muscular movements 
is first manifested in the hands, and may be very pronounced at a 
time when the general muscular power is but little weakened. 
Thus, a man may be able to lift many pounds, although he can- 
not write his own name. The acute development of such a loss 



454 DIAGNOSTIC NEUROLOGY. 

of muscular control occurring in a man of middle age, without 
obvious cause, is a serious symptom, and probably, in the majority 
of cases, is prodromic of general paralysis. It is especially to be 
noticed very early in engravers and other persons whose daily 
vocation requires great technical skill. 

A varying inequality of the pupils may occur very early, al- 
though more constant in the later stages of the disease. It may 
be associated with excessive dilatation or contraction. When there 
is no focal brain-lesion, and no disease of the neck or of the cer- 
vical spinal cord, this symptom is almost pathognomonic. 

The departure of the speech from the norm in general paraly- 
sis is partially of mental and partially of physical origin. As a 
consequence of the loss by the lips and tongue of their delicacy 
of movement, there is a difficulty of pronunciation, which is es- 
pecially manifested with lingual and labial consonants and in the 
syllables of long words. This causes a peculiar stuttering or 
hesitation, with some thickness of speech and an occasional elision 
of syllables, so that the speech somewhat resembles that of intoxi- 
cation. In advanced stages of the disease the uncertainty of the 
movements of the lips and tongue is plainly visible to the eye, 
and is associated with tremor, or, more correctly, with tremulous- 
ness. In general paralysis the mind thinks slowly and imper- 
fectly : it fails not only in the formation of ideas, but also in the 
quick association of these ideas with suitable words. There is, 
consequently, slowness as well as hesitation of speech. In some 
cases the mental actions seem to be performed in a rhythmical 
manner, giving rise to a peculiar utterance which somewhat re- 
sembles that used by the school-boy in scanning Latin poetry, 
and hence often spoken of as the " scanning speech/' There 
is also in many cases a use of improper words. Not rarely the 
paralytic talker drops a word from his sentence or repeats a 
word ; mayhap he elides or repeats a whole clause. Movement 
of the jaws similar to mastication may take place, and even cause 
grinding of the teeth or champing of the jaws. 

The loss of adroitness and exactitude of movement may first 
appear in the hands. The handwriting becomes shaky and irreg- 
ular, and the letters are ill formed, even widely separated from 
one another, sometimes resembling hieroglyphs rather than mem- 
bers of the Roman alphabet. Very frequently the finely-graded 



DISTURBANCES OF INTELLECTION. 455 

strokes of correct writing disappear in a common, thick, uncertain 
line. The writing not only shows the physical degradation, but 
has the same mental characteristics as the speech. The ideas are 
often incongruous and devoid of proper association, and the words 
incorrectly used. Letters are dropped out, syllables omitted or 
repeated, and words or even clauses elided or interjected. 

The gait may be early affected. It becomes awkward and un- 
certain, the steps may be long and slightly irregular, and the 
patient\s lack of control over his movements comes out sharply 
when he attempts suddenly to turn or to alter his position. As 
the disease progresses, the gait becomes slow, heavy, and unsteady, 
whilst the widely-separated feet readily trip over an inequality or 
unexpected obstacle. In the advanced stages the posture of the 
patient resembles that of old age, the body being bent awkwardly 
forward or to one side. With difficulty he walks with a slow, 
unsafe, swerving gait ; in the most advanced stages tottering for- 
ward, aided by an arm or some support, and day by day losing 
control over his limbs, until he becomes bedridden. 

The symptoms of general paresis may be summed up to be — 
change of character ; progressive mental deterioration, with delu- 
sions of grandeur, emotional exaltation, or emotional depression ; 
occasional maniacal outbreaks and epileptic attacks; progressive 
physical deterioration, as shown by irregularity of the pupils, dis- 
order of speech, loss of control over the movements of the hands 
and legs : all symptoms finally being swallowed up in a complete 
paralysis of intellection and of voluntary motion. When the 
disease is fully formed there can be no difficulty in recognizing 
it. In the earlier stages, however, the diagnosis may be almost as 
difficult as it is important. In making it, the age of the patient 
and the presence in the history of the ordinary causes of general 
paralysis should have great weight. 

In civil life the affection is most frequent between forty and 
fifty years of age, although it not rarely occurs as early as thirty 
years, and more frequently as late as the fifty-fifth year. In 
sailors and soldiers Mickle noted that the average age was about 
thirty-three. The causes of the affection appear to be habitual 
emotional and, to a less extent, purely intellectual over-excite- 
ment; excessive use of alcohol; sexual excesses, especially when 
combined with syphilis ; and, much more rarely, sunstroke and 



456 DIAGNOSTIC NEUROLOGY. 

other traumatisms. Whenever any of the earlier symptoms ap- 
pear in a man of middle age whose life-history presents the causes 
of the disease, general paralysis should be considered imminent, 
and, whilst it may not be proper to give a positive opinion, it is 
usually right to take measures of restraint. The earliest important 
symptoms are an apparently causeless change of character, epi- 
leptic attacks which cannot be otherwise explained, and distinct 
mental symptoms such as have been described. When the diag- 
nosis rests between general paresis and some other form of mild 
insanity, the condition of the memory should be carefully studied. 
Under these circumstances distinct failure of memory points very 
strongly towards general paresis. Among the physical symptoms 
the most important are inequality of the pupils, and loss of power 
of executing fine movements, such as those of writing, of buttoning 
or unbuttoning the clothes, of dancing, etc. These physical symp- 
toms usually come on early ; some of them may even precede dis- 
turbance of intellection. On the otlier hand, I have seen the 
physical health greatly improve and the muscular power increase 
in the earlier stages of the disorder, — at a time, too, when the 
intellectual symptoms were very pronounced. 

Cerebral Sclerosis. — Sclerotic affections of the brain more 
usually take the form of a multiple sclerosis than that of a wide- 
spread cortical change. In multiple sclerosis the only mental aber- 
ration that is common is a progressive loss of power, especially 
marked, at least in the earlier stages of the disease, in regard to 
the memory of recent events. If considerable cortical regions be 
involved, complete dementia may result even in a disseminated 
sclerosis. In terminal dementia it is not uncommon for sclerotic 
changes to be detected at the autopsy, and it is probable that 
various cases supposed to be instances of pure insanities are really 
examples of the earlier stages of a cerebral sclerosis. At present, 
however, we are not able to connect mental aberration with incip- 
ient sclerotic disease of the brain-cortex, or in any way to diag- 
nose the existence of the latter, unless it manifests itself also by 
physical symptoms. For further remarks upon this subject, see 
Syphilitic Insanity, p. 464. 



DISTURBANCES OF INTELLECTIOX. 457 

DIATHETIC INSANITIES. 

The diathetic insanities are not distinct forms of disease, but 
groups of symptoms of various and varying character, which are 
the outcome of constitutional vice or disease. Thus, there is noth- 
ing in the symptoms of a gouty insanity which would enable us 
to diagnose the nature of the case. The cause of the mental 
aberration in such a case can be recocrnized onlv bv recosnizino; 
the presence of lithsemia. The importance of distinguishino- an 
insanity of the present class lies in the fact that relief is to be 
obtained not by treating the insanity, but by treating the diseased 
condition which is the cause of the mental disorder. 

The most important of the diathetic insanities are the Gouty, 
the Epileptic, the Hysterical, and the Toxemic. 

Gouty Insanity. — It is well known that gouty paroxysms are 
frequently accompanied and preceded by peculiar nervous irrita- 
bility. At such times there is a depression of spirits, with an irri- 
tability so great that it can scarcely be controlled by the patient. 
In some cases these symptoms become so intensified as almost to 
amount to insanity ; moreover, hallucinations, delusions, loss of 
mental power, — indeed, almost every conceivable manifestation of 
mental disorder, — may be directly or indirectly caused by gout. 
Carrol in 1859 said, '^ Gouty mania is occasionally seen;" and in 
1875, Dr. P. Berthier (Des Neuroses diathesiques, Paris) published 
a collection of forty-six cases of nervous disease attributable to 
gout ; one of hallucinations ; one of migraine ; four of tetanus ; 
three of chorea ; one of hypochondria ; seven of epilepsy ; one of 
paralysis; and twenty-six of mental affections, including in these 
dementia, melancholia with stupor, mania. Although in some of 
these cases the evidence is not at all positive that gout was the 
materies morbi, yet in others the relation seems to have been clearly 
made out. 

In his paper read before the International Congress at London, 
1881 (iii. 640), Dr. Eaynor supported the following conclusions: 

1. Protracted gouty toxsemia, when not very intense, usually 
results in sensory hallucinations or melancholia. 

2. Sudden and intense toxaemia results in mania or epilepsy. 

3. Intense and protracted toxsemia usually results in general 
paralysis. 



458 DIAGNOSTIC NEUROLOGY. 

4. If there be a tendency to vascular degeneration from plum- 
bism, alcoholism, etc., varying degrees of dementia are produced. 

In the discussion which followed the reading of Dr. Raynor's 
paper, Drs. Savage and Crichton Browne, of London, both ex- 
pressed the belief that gout does cause insanity, the latter, how- 
ever, qualifying by the statement, " only where there is hereditary 
predisposition to insanity."* 

The conclusions of Dr. Raynor are borne out by a case of 
my own. A lady at regular intervals of four years had had a 
number of attacks of severe gout associated with great depression 
of spirits at times amounting almost to pronounced melancholia. 
Finally, at the end of four years of health, the patient was 
seized with symptoms of acute dementia or stuporous melancholia, 
associated with marked tenderness of the nerve-trunks, and, in 
certain portions of the body, violent neuralgia, and a urine that 
was loaded with uric acid and urates. Death occurred after some 
weeks from oedema of the lungs. At the autopsy there was found 
gouty kidney and a remarkably pronounced atheromatous degen- 
eration of the cerebral vessels, the lumina of some of the basilar 
arteries of the brain being almost obliterated. 

Epileptic Insanity. — In considering the relations of epilepsy 
to mental aberration it is necessary to discuss separately the 
mental symptoms which may occur in or replace a single par- 
oxysm, and those which are the result of a long succession of 
paroxysms. The paroxysmal mental symptoms may be considered 
under the heading of Epileptic Automatism and Epileptic Mania. 
In a very large proportion of cases the epileptic paroxysm is 
followed by profound sleep, from which the patient wakes in a 
more or less dazed condition, which may continue for some mo- 
ments. In many cases the patient may, after the epileptic par- 
oxysm, appear to be conscious and yet not really be himself, as is 
shown by his subsequently being unable to remember anything 
that has happened shortly after the convulsion. In some cases 
distinct hysterical manifestations accompany this post-epileptic 
condition, and even hysterical convulsions may occur. 



^Further proof of the connection between gout and insanity may be found 
in the Paris Thesis of M. Belliard (1882, No. 269), in which are detailed vari- 
ous cases. 



DISTURBANCES OF INTELLECTION. 459 

The so-called automatic actions of epilepsy are probably in the 
majority of cases post-paroxysmal^ and occur during the period 
which has just been spoken of. In their simplest form these 
actions consist in the doing of something which is usually incon- 
gruous. According to Gowers, a very common performance is 
that of undressing. In other cases the patient habitually lays 
hold of all small objects near him and secretes them about his 
person. In a case related by Gowers, the patient was accustomed 
to cut bread^ butter it, and eat it as fast as possible. Sometimes 
the actions are very complex. Gowers relates the case of a car- 
man who, for an hour after his fit, would drive through the most 
crowded streets of London without accident. 

Sometimes the subject of epileptic automatism will get up after 
the convulsion and continue with whatever work was in hand 
when the attack developed, although, in fact, perfectly uncon- 
scious. Thus, a woman under my own care has been attacked 
with the convulsion as she was setting the table for a meal : get- 
ting up in two or three minutes, she would continue to dish up 
the dinner, arrange the plates, etc., in an apparently natural way, 
but would after a time suddenly wake up and have no knowl- 
edge of what she had done. Other cases of epileptic automa- 
tism have already been cited (see page 107), and sufficient ex- 
amples given to show that the acts may apparently be pur- 
posive or purposeless, and most simple or most complex, and 
that often it is very difficult to persuade by-standers that the 
patient is not in a condition of true consciousness. In many 
cases of epileptic automatism no display of emotion is made; 
sometimes, however, the patient is hilarious, and even aggressively 
aflFectionate, and still more frequently rage or violent emotions 
are manifested. It is through cases in which violent i)assion 
asserts itself that epileptic automatism passes into the so-called 
epileptic mania, — which, indeed, may be very logically considered 
as a form of the automatism associated with excited emotions. 

Epileptic automatism is more apt to follow paroxysms of petit 
mal than the major convulsions. Not rarely the vertiginous and 
convulsive symptoms are so slight that they are discoverable only 
by the most careful observation ; and it is probable that in some 
cases the automatic actions are the sole outcome of the epileptic 
discharge, all the other stages of the paroxysm being wanting. I 



460 DIAGNOSTIC NEUROLOGY. 

have certainly seen the attack of epileptic automatism precede 
the general convulsion. 

The actions of epileptic automatism, as already stated, may so 
closely resemble those of the normal state as to make the recog- 
nition of their true nature somewhat difficult. The characteristic 
feature is, however, that the patient does not after his recovery 
remember anything of the occurrences which have taken place 
during the automatic state. The period is an absolute blank 
with him. It is hardly necessary to point out the close rela- 
tions which exist between the epileptic automatism and the so- 
called double consciousness. The fact that in typical double 
consciousness the subject shows vivid recollection of occurrences 
during previous paroxysms of the same type affords some dis- 
tinction ; but in nature cases appear to grade into one another, 
the connecting remembrances being sometimes very slight and 
sometimes very vivid. 

In epileptic mania, so called, there is violent excitement and 
delirium, which may take the form of an acute mania or of an 
agitated melancholy : in either case the incoherence is usually less 
than in the corresponding non-epileptic affection. Not rarely after 
a primary period of violent disconnected speech the patient is 
seized with an ambitious or mystic delirium, or sometimes a delir- 
ium of persecution, or, more rarely, with an erotomania, in which 
sentence after sentence flows out with extraordinary volubility. 
The attack usually comes on suddenly, and is always accompanied 
by hallucinations, which sometimes develop brusquely, or, more 
rarely, in the course of a few minutes. The hallucinations affect 
all the senses and give rise to delusions which conform with the 
type of the emotional disturbance. The delirium may last for a 
few moments to several days. It is especially characterized by 
the tendency to acts of extreme violence, — to suicide in the mel- 
ancholic form and to homicide in the maniacal variety. 

In epileptic fury the subject has no control over his actions, 
and when murder and other crimes are committed it is important 
that the medical jurist recognize the true nature of the attack. 
When the mania is of mild type the danger of overlooking its 
character is greatest. The diagnosis is to be made by obtain- 
ing the history of previous attacks of epilepsy, by the brutality 
and causelessness of the crime, and especially by the fact that the 



DISTURBANCES OF INTELLECTION. 461 

patient has no memory of occurrences which took place durincy 
the mania. In a certain proportion of the cases the attacks of 
epileptic mania are repeated in exact counterfeit one of the other. 
The maniacal outbreak, may, however, not recur for a ^reat 
length of time. The difiScuIties of the expert are increased by 
the fact that the first paroxysm of an epilepsy may take the form 
of a furious outbreak of epileptic mania. Under these circum- 
stances it may be essential that the patient be kept for a length 
of time under surveillance, since, although the circumstances of 
the paroxysm may satisfy the mind of the medical expert, they 
may fail to carry conviction to judge and jury. Esquirol states 
that the homicidal mania of epilepsy is never radically cured, 
and that its subject is always liable to a fresh outbreak. Whether 
this be absolutely true or not, it is certain that the recurrence is 
suflSciently habitual to demand the perpetual surveillance of the 
epileptic criminal.* 

Epilepsy frequently leads to mental degradation, which may end 
in complete dementia. More rarely a permanent insanity develops 
in the epileptic, although it is doubtful whether the convul- 
sions in these cases are not the direct outcome of the original 
neurotic vice, rather than the cause of the insanity. The type 
of such insanity is said to be usually melancholic, with delusions 
of persecution and suicidal impulses. The characteristic mental 
state of chronic epilepsy is progressively lowered mental power, 
with a peculiar irritability and brutal selfishness, and outbreaks of 
furious anger on the slightest provocation. Even while the men- 
tal powers are still active, epileptics very frequently are peculiarly 
irritable and revengeful. After a paroxysm these tendencies are 
increased. The tendency of epilepsy to cause dementia is usually 
in direct relation to the earliness of the age at which it first ap- 
pears, as is shown in the following analysis of fourteen hundred 
and fifty cases collected by Gowers : 

Age of First Mental Defect 

Appearance. developed. 

Under 10 years 55 per cent. 

Between 10 and 19 years 36 

'* 20 and 30 years 3 '' ** 

Over 30 years ^ 

^ Por further details upon this subject consult M. Y. Magnan, L'tpilepsie, 
Paris, 1882. 



462 DIAGNOSTIC NEUBOLOGY. 

Hysterical Insanity. — Severe hysteria is usually accompanied 
by a peculiar mental organization, which may amount to a distinct 
and characteristic psychosis. In its aggravated form this psy- 
chosis ought to be considered as belonging to the partial insanities, 
and ought to acquit its victim of legal responsibility and to aflford 
suflBcient grounds for restraint. The peculiar characteristics of 
this hysterical temperament have been so vividly set forth in a 
few sentences by Dr. Folsom that we quote his words : 

" It is characterized by extreme and rapid mobility of the mental 
symptoms, — amnesia, exhilaration, melancholic depression, theat- 
rical display, suspicion, distrust, prejudice, a curious combination 
of truth and more or less unconscious deception, with periods of 
mental clearness and sound judgment which are often of greater 
degree than is common in their families; sleeplessness, distressing 
and grotesque hallucinations of sight, distortion and perversion of 
facts rather than definite delusions, visions, liypersesthesias, anaes- 
thesias, paraesthesias, exceeding sensitiveness to light, touch, and 
sound, morbid attachments, fanciful beliefs, an unhealthy imagi- 
nation, abortive or sensational suicidal manoeuvres, occasional out- 
bursts of violence, a curious combination of unspeakable wretched- 
ness alternating with joy, generosity and selfishness, — of gifts 
and graces on the one hand and exactions on the other. The 
mental instability is like a vane veered by every zephyr. The 
most trifling causes start a mental whirlwind. There is no dis- 
ease giving rise to more genuine suffering or appealing more 
strongly for sympathy. Yet when this is freely given it does 
harm. One such person in the house wears out and outlives one 
after another every healthy member of the family who is unwisely 
allowed to devote herself with conscientious zeal to the invalid." 

During the paroxysm of major hysteria there is a period of 
delirium which may simulate acute mania, and I have seen 
recurring attacks of hysterical epilepsy replaced by a furious out- 
break of acute mania, lacking in none of the symptoms charac- 
teristic of that disease. It seems to me that in such a case the 
maniacal explosion must be looked upon as the direct outcome 
of the hysterical neurosis, and that therefore the existence of an 
hysterical acute mania not in itself distinguishable from ordinary 
acute mania must be acknowledged. In most cases in which such 
maniacal symptoms exist the neurosis is so thoroughly engrafted 



DISTURBANCES OF INTELLECTION. 463 

upon the constitution that permanent recovery is not possible, 
the patient during life suffering from various forms of hysterical 
attack, and being always possessed of the peculiarities which have 
already been spoken of as characteristic of the hysterical tem- 
perament. Hysterical symptoms may occur during almost any 
form of insanity, but do not warrant our looking upon such a 
melancholia or mania, or whatever form the affection may take, 
as hysterical, scarcely more than we should be warranted in con- 
sidering pneumonia when associated with hysterical symptoms as 
hysterical. At the same time, the relation of the hysterical tem- 
perament to monomanias and to general insanities is distinct, and, 
according to my belief, it is entirely possible for any form of 
insanity to be simulated by symptoms which have their origin in 
the original faulty organization that is the basis of chronic hys- 
teria : moreover, such faulty nerve-organization is closely allied to 
the peculiar neurotic temperament which is the basis of much 
insanity. 

Syphilitic Insanity. — Insanity of any type may occur with- 
out definite organic brain-disease in a person who has syphilis. 
In such a case the syphilis, by causing mental distress or general 
failure of health, may be a potent factor in the production of the 
mental disease; but there is at present no reason for believing that 
syphilis can directly produce insanity without a demonstrable 
brain-lesion. By interfering with the circulation of the brain- 
cortex, or by propagation of the inflammation to the cortex, gum- 
matous meningitis may profoundly influence the brain-functions, 
and experience has shown that the aberrations produced by these 
organic changes may simulate almost any form of insanity. Such 
insanity offers no characteristic symptoms, and really belongs to the 
complicating insanities. The significance of the mental disturb- 
ance is to be made out by recognizing the physical symptoms of 
the organic lesion. Violent headache, epileptic attacks, ocular or 
other forms of local palsies, local spasms, localized neuralgic pains, 
or other evidences of generalized or localized gummatous inflam- 
mation, almost invariably enable us to make out at once the nature 
of the disease. Syphilis may, however, produce a wide-spread 
structural disease of the brain-cortex without implication of the 
membranes or of the basal nerves, and the connection between 
the consequent mental derangement and the syphilitic infection 



464 DIAGNOSTIC NEUROLOGY. 

may be very difficult to trace. There may be no symptoms of a 
focal disease of the brain^ and, indeed, no distinct proof of the 
existence of gross organic lesion. 

Sometimes the insanity is maniacal ; now it takes the form of 
religious melancholy, again it resembles confusional mania, rapidly 
passing into dementia. There is certainly a form of sclerosis of 
the cerebral convolutions which has a more or less direct connec- 
tion with syphilis, in which the symptoms during life are those 
of a chronic insanity with a gradual deterioration of the mental 
powers, ending in complete dementia. In one case in which I 
had the opportunity to follow the symptoms for a long time 
during life, and to confirm the diagnosis by a post-mortem exam- 
ination, there was no headache, but for many months a peculiar 
mental condition marked by great restlessness, with a perpetual 
desire to be upon the go, with excessive volubility and a curious 
loss of the power of judging of the relative importance of things, 
so that the man would talk for hours about a trifling incident 
and have no interest in events of the utmost importance. In 
the course of time wild maniacal symptoms were added, and the 
case passed into an apparently ordinary dementia. 

Although medieval records prove that a patient whose symptoms 
are apparently those of a pure insanity may have a syphilitic 
brain-disease which will yield to treatment, such cases are ex- 
traordinarily rare. In an experience covering several hundred 
cases of brain-syphilis I have never seen one. I have seen a 
number of attacks of an apparent pure insanity in persons who 
have had syphilis, but have never been fortunate enough to get 
good from antisyphilitic remedies. It is otherwise with cases 
whose symptoms resemble those of general paralysis of the insane. 
I think we must recognize as established the opinion of Voisin,* 
that there is a syphilitic periencephalitis which presents symptoms 
closely resembling those of general paralysis. Such cases are 
examples of the pseudo-paralysie generate of Fournier.f Tlie 
question as to the diagnosis of these cases from the true incurable 
paresis is very important, and has been considered at great length 
by Voisin,! Fournier,§ and Mickle.|| The points which have 

* Paralysie generate des AlieneSj 1879. t La Syphilis du Cerveau, Pans, 1879. 
J Loc. cit. 5 Loc. cit. || Brit, and For. Med.-Chir. Rev.^ 1877. 



DISTURBANCES OF INTELLECTION. 465 

been relied upon as diagnostic of syphilitic pseudo-general paral- 
ysis are — the occurrence of headache, worse at night and present 
among the prodromes; an early persistent insomnia or somnolence; 
early epileptiform attacks ; the exaltation being less marked^ less 
persistent, and perhaps less associated with general maniacal rest- 
lessness and excitement; the articulation being paralytic rather 
than paretic; the absence of tremulousness, especially of the upper 
lip (Fournier) ; and the eflFect of antispecific remedies. 

When the conditions in any case correspond with the characters 
just paragraphed, or when any of the distinguishing characteris- 
tics of brain-syphilis, as previously given, are present, the prob- 
ability is that the disorder is specific and remediable. But the 
absence of these marks of specific disease is not proof that the 
patient is not suffering from syphilis. Headache may be absent 
in cerebral syphilis, as also may insomnia and somnolence. Epi- 
leptiform attacks are not always present in the pseudo-paralysis, 
and may be present in the genuine affection; megalomania may 
be very pronounced in specific insanity. A case with very pro- 
nounced delirium of grandeur, in which the autopsy revealed 
unquestionably specific brain-lesions, may be found in Chauvet^s 
ThesiSy p. 31. I have seen symptoms of general paralysis occur- 
ring in persons with a specific history in which of these so-called 
diagnostic differences the therapeutic test was the only one that 
revealed the true nature of the disorder. In these cases a pri- 
mary, immediate diagnosis was simply impossible. 

In conclusion, I may state that it must be considered as at 
present proved that syphilis may produce a disorder whose symp- 
toms and lesions do not differ from those of general paralysis ; 
that true general paralysis is very frequent in the syphilitic; that 
the only constant difference between the two diseases is as to cura- 
bility ; that the curable sclerosis may change into or be followed 
by the incurable form of the disease. As a careful antisyphilitic 
treatment can do no harm, in any doubtful case of insanity it 
should be essayed. 

Alcoholic Mental Disorders. — Mental disturbances produced 
by abuse of alcohol may be divided into the subacute and chronic 
forms, to which the names Delirium Tremens and Alcoholic 
Insanity may be assigned. 

Delirium Tremens. — Delirium tremens is a peculiar series of 

80 



466 DIAGNOSTIC NEUROLOGY. 

acute symptoms which are produced by excessive drinking. The 
affection is especially apt to develop upon the sudden cessation in 
the use of the stimulants^ but may come on during the debauch. 
In their mildest form the symptoms constitute that condition 
known by old drunkards as '^the horrors," in which the sleep is 
disturbed, the hand tremulous, the mind weak and confused, and 
the patient troubled with frightful imaginings, vague alarms, 
and an apparently causeless depression of spirits. When the at- 
tack is more severe, hallucinations of sight, of hearing, and, more 
rarely, of touch, occur. These hallucinations always have in them 
an element of terror or of horror. Disgusting objects, such as 
snakes, toads, rats, and mice, and similar unclean creatures, crawl 
over the bed or the person. Voices predicting evil, or bringing 
messages of remorse, or uttering threats of punishment, are heard. 
The patient may seem violent, and may even attack his attendants, 
but the violence is that of terror, and not of aggression. The 
attack is an attempt at defence. There is great insomnia, and 
usually when the patient can be made to sleep the mind is clear 
after the awakening. This is not, however, invariably the case: 
I have seen delirium tremens gradually pass through successive 
days of wakefulness and nights of sleeping into a chronic mania 
not readily to be distinguished from that arising from other causes. 
In the earlier attacks of delirium tremens occurring in very robust 
people, when all the mucous membranes are irritated, and when 
probably there is direct irritation of the brain and its meninges, 
there may be a slight febrile reaction and even a strong and excited 
pulse; but the disease is typically asthenic, with loss of muscular 
power, tremulousness, and rapid feeble pulse, and when death 
occurs it is from exhaustion. Cardiac failure is in such cases 
always to be guarded against. 

Sometimes the patient suffering from delirium tremens has 
sufficient rationality to receive his physician with a quiet, gentle 
courtesy, and to answer questions without irritation. It will be 
noted, however, that he is evidently preoccupied, and that occa- 
sionally he turns his head or casts furtive glances from one part 
of the apartment to the other; and a little finesse will reveal the 
fact that during the whole time he is seeing visions or hearing 
sounds, or is at least laboring under a profound a{)prehension of 
attack. 



DISTURBANCES OF INTELLECTION. 467 

The diagnosis of delirium tremens is usually easy, even when 
the history of the case is not clear. The peculiar terror under- 
lying all the delusions, hallucinations, and attempts at violence 
is characteristic, as is also the tremulousness of the hands when 
extended. When pneumonia occurs during a period of delirium 
tremens the type of the delirium may change, tremors may be 
lost, and the patient may become so violently aggressive as to lead 
to a mistaken diagnosis. 

AlcoholiG Insanity.- — The prolonged use of alcohol may lead 
to a gradual functional and finally structural alteration of the 
nervous system. Under the continuous influence of the narcotic 
the brain performs its functions slowly and imperfectly and the 
mental movements become sluggish and weak; the memory is 
greatly impaired ; the power of fixing the attention steadily di- 
minishes, but the intellectual weakness is especially shown by the 
lessening of the power of the will, so that not only is the judg- 
ment uncertain but its dictates are not carried out. There is 
also a distinct tendency to emotional depression, and often a pecu- 
liar suspiciousness, which is the ground-work for delusions. A 
step further, and hallucinations haunt the victim. The route to 
insanity and irresponsibility from this condition is short. Out of 
such a state is easily developed the most characteristic and fre- 
quent form of alcoholic insanity, — namely, that with depressive 
delusions. In some cases this variety of alcoholic insanity ap- 
pears suddenly with symptoms for a time not to be distinguished 
from delirium tremens. Indeed, I think it perfectly correct to 
say that a patient may pass from delirium tremens into alcoholic 
insanity. 

It is affirmed that headache and other symptoms of sudden con- 
gestion of the brain occasionally usher in the attack of alcoholic 
insanity. When the symptoms are active, hallucinations* are very 
numerous, constantly changing, and almost always are such as to 
inspire terror or disgust. In a very short time they are accom- 
panied by delusions of persecution: voices of reproach, threaten- 
ing, or remorse, mocking faces, unclean beasts, tormenting devils, 



* Spitzka says they are usually of vision ; Dr. F. Lentz (De V Alcoholisme) 
says that they are almost exclusively of hearing ; my experience is that both 
forms of hallucination are frequent. 



468 DIAGNOSTIC NEUROLOGY. 

— these and similar visions drive the victims into profound melan- 
choly, and finally may lead to suicide or murder. According to 
Spitzka, the delusions of chronic alcoholism almost always relate 
to the sexual organs, to the sexual relations, or to poisoning. Un- 
derlying this variety of alcoholic mania is frequently an intense 
fear, which may lead to violence, as when a man kills his w^ife 
because he fears that she will poison him. Not uncommonly the 
depressive sexual delusion leads to an outburst of uncontrollable 
jealousy and rage, so that wife-murder from motives of jealousy 
is not a rare result of alcoholic mania. There is in some of these 
cases a very marked relation between the presence of alcohol in 
the blood and the insane outburst. The drunkard may be, when 
not under the influence of the poison, fairly rational, but is con- 
verted by alcohol into a wild beast, although he has few or none 
of the ordinary symptoms of intoxication. Tiie man may walk 
straight, and talk rationally on general subjects, but be profoundly 
under the influence of a depressive or persecutive delusion which 
disappears when the blood is free from alcohol. Thus, in the case 
of a man recently tried at Elkton, Maryland, for the murder of 
his brother-in-law and child, it was proved that when the prisoner 
had abstained for two or tliree weeks from liquor he was kind to 
his family, and attached to his wife, in whom he also had com- 
plete confidence : so soon as he began to drink again he would 
become possessed with the idea that "she was no better than a 
common whore," and on several occasions he had attempted to 
murder her. The immediate recovery of the man during absti- 
nence removed his case from being fairly considered as one of 
insanity; but, although a few moments before the murder the 
man had been talking rationally, the court came to tlie conclusion 
that he was in a state of temporary insanity from the influence 
of alcohol, — that is, in the condition of legal drunkenness, — and 
that the degree of his crime was therefore manslaughter: it being 
the theory of the law that a sudden murder committed during 
intoxication is not committed with that malice prepense which is 
necessary to constitute a murder in the first degree. The prisoner 
had been drinking heavily for twenty-four hours: he first shot 
his brother-in-law in front of his house, then went in and called 
his two little children to himself, and blew out the brains of his 
oldest son whilst the child was on his knees praying for mercy. 



DISTURBANCES OF INTELLECTION. 469 

The second son, seizing hold of his father's pantaloons, pleaded 
for his life, but, seeing that his father continued to load his gun, 
ran for the front door; as he suddenly stopped to open it, the 
father fired, the shot tearing away the brim of the boy's hat. 

The relation between depressive alcoholic insanity and mania 
a potu is, as has been already stated, very close. Insomnia, emo- 
tional excitement, especially connected with fear, hallucinations, 
and delusions, are common to each; but the tremors are more 
marked in delirium tremens, and when an attack of alcoholic in- 
sanity is acute and tremors are pronounced, it may be considered 
to be mania a potu. 

Dr. F. Lentz (loe, cit, page 491) calls attention to a form of 
alcoholic insanity with expansive delusions and hallucinations of 
sight and hearing which, very strangely, in most instances relate 
to God and a future state. Visions of supernatural beings, and 
especially of the Deity bathed in an aureole of light, perpetually 
haunt the patient; the ministrations of angels seem to bring relief, 
or mayhap the voice of God himself is heard in command or in- 
struction. 

It would appear that two forms of alcoholic insanity must be 
recognized, — one a lypemania, or melancholia with delusions of 
persecution ; the other a megalomania, with a strong tendency to 
religious hallucinations. 

PURE INSANITIES. 

In the present group are included those insanities in which 
there are no other evidences of brain-disease. The group includes, 
in other words, all cases of ordinary insanity, so called, in which 
there are no physical symptoms, and in which we still have no 
knowledge of the disease which produces the insanity. 

For the purposes of clinical study, mental derangements of this 
class are conveniently divided into sub-groups, which in default 
of better names may be known as Complete and Incomplete 
Insanities. 

Complete Insanities are those in which the disorder is wide-spread, 
involving all the faculties of the mind. The delusions in these 
cases are usually unsystematized. 

Incomplete Insanities are those in which the whole mental 
mechanism is not involved, although the mental anomalies may 



470 DIAGNOSTIC NEUROLOGY. 

be so pronounced as to dominate the thinking as well as the life 
of the individual. The delusions are usually systematized.* 

COMPLETE INSANITIES. 

Insanities of this group may be divided for clinical study into 
those in which the attacks are single in the individual, or, if 
recurrent, have no definite time-relations with one another, and 
those in which the periods of mental aberration recur repeatedly 
at more or less regular intervals. The terms Non-Periodic In- 
sanities and Periodic Insanities may be employed to designate 
these groups of cases. 

The distinction between these groups is important, because non- 
periodic insanities are not necessarily the outcome of an original 
vice of constitution, and are often recovered from ; whilst periodic 
insanities are the expression of an original imperfect organization 
or development in the brain of the patient, who rarely, if ever, 
gets completely well. 

COMPLETE NON-PERIODIC INSANITY. 

Insanities of this group may, in order to facilitate discussion, 
be usefully divided into three groups, on the basis of the emo- 
tional conditions. The division is given below. 

It must be remembered that this classification is not offered 
as separating diverse diseases, but as affording an easy means of 
recognizing clinical symptomatic groups representing affections 
of whose pathology we have no distinct knowledge. 

* In separating these two groups I desire to re-aver my belief that the classi- 
fication is practical rather than scientific, and that there are gradations be- 
tween the most severe complete insanities and the most partial form of the 
disorder, so that we may, at times, be at a loss to know in which class an 
individual case of insanity belongs. There is, however, usually no diflSculty 
in arranging the cases. A very important difference which has been dwelt 
upon by recent alienists as distinguishing cases of the two classes is in the 
alleged fact that in complete insanities the delusions are always unsystema- 
tized, and in the incomplete they are systematized. I have already stated 
(see page 432) that the distinction between systematized and unsystematized 
delusions is, in my opinion, to some extent an arbitrary one, and that in 
nature every gradation between the thoroughly systematized and the unsys- 
tematized delusion may be met with. 



DISTURBANCES OF INTELLECTIOX. 



471 



Emotional State. 

Exaltation. 
Depresssion. 



Apathy from loss of 
activity, normal, 
or variable. 



Mania 



lia J 



Acute. 
Chronic. 



Melancholia j^^^^^^^^li^- 
<- Katatonia. 

Imbecility. 



Mental Dete- 
riorations. 



Form of Insanity. 



Organic. 



.,.{ 



Senile. 



Primary Dementia. - 



^ Terminal Dementia. 



Developmental. [ Hebephrenia. 

Shock. 

Primary Con- 
fusional In- 
sanity. 

Stuporous In- 
sanity. 



Miscellaneous. - 



Mania. 

Mania is a mental condition in which there is an emotional 
exaltation, accompanied by illusions, hallucinations, delusions, 
great mental and physical excitement, and a complete loss of the 
inhibitory power of the will : in acute cases, and frequently in 
the chronic forms of the disease, there is a marked destructiveness 
and a tendency to violence. 

Acute Mania. — Acute mania is sometimes developed with great 
suddenness ; more often it is preceded by a prodromic stage of 
emotional depression. The depressive stage may last from a few 
days to three months. There is often a sense of lassitude, with 
inability or disinclination to work, a lack of the usual power of 
fixing the attention, depression of spirits, and a feeling of unrest 
which causes the subject to worry perpetually about himself; the 
bowels are costive, the appetite is poor, and dyspeptic symptoms 
are often troublesome. The resemblance of this condition to a 
mild melancholy is so close that it is frequently spoken of as the 
melancholic stage of mania. Usually, after a time, the subject 
gradually returns to his normal state, except perhaps that his 
perceptions are abnormally quick, and that he is abnormally 
happy or even gay. Rapidly now the emotional excitement rises, 
delusions and hallucinations appear, and the maniacal stage is 
reached. When the affection is at its height its victim raves 
incessantly, shouting out a perpetual stream of incoherent threat- 
enings, revilings, obscenities, and blasphemies. With a pro- 
digious and untiring strength he rushes about his apartment, 
struggles with his attendants or his mechanical restraints, tears 
into shreds whatever clothing he can lay his hands upon, destroys 



472 DIAGNOSTIC NEUROLOGY. 

all about him that is breakable, smears his excrement over his 
person and surroundings, and so passes whole days and nights in 
unceasing fury. Even if for brief intervals sleep comes, it is 
filled with dreams, and is broken and fitful. The hallucinations 
and unsystematized delusions are constantly changing. There is 
usually great sexual excitement, as shown by satyriasis or nymph- 
omania. There is often a marked blunting of sensation, so that 
the maniac does not feel the wounds he inflicts upon himself in 
his blind fury. 

In very many cases of acute mania the symptoms are milder, 
but of similar character to those just detailed. Restless, licentious, 
blasphemous, incoherent, obscene, the maniac looks the fury of 
the previous picture; or, occupied by his own hallucinations and 
delusions, he may be rapt in a delirium of enjoyment. In a 
still milder form, acute mania shows itself in incoherence, ir- 
rationality, restlessness, evidences of hallucinations and delusions 
with marked insomnia, and total loss of modesty and of care for 
or notice of the usual relations of life. 

In the mildest possible form of the disease — Hypomania — the 
hallucinations may be wanting, and the mania reveal itself only 
in a change of character, a peculiar egotistic hilarity, perpetual 
extravagances, restlessness, increased sexual appetite with lessened 
'control of the will-power, leading to great sexual excesses, and a 
tendency to brutal violence. The diagnosis in these cases is often 
very difficult, and can be made only by noticing the complete 
alteration in the life, disposition, and mental, moral, and physical 
habits of the individual. Indeed, I believe that the maniacal 
state grades insensibly by rare cases into the normal condition, 
and that there are states in which the will still exerts its control, 
but the mental and moral attributes are so altered that the man 
is not his natural self. Every one has his hours and sometimes 
days of exaltation, and exactly when or how far the mood triumphs 
over the individual who shall say ? 

In most cases of acute mania periods of excitement alternate 
with periods of comparative calm. The usual duration of the 
disease is from three to six months, although recovery may 
occur in a few days or be postponed for over a year. Death 
may take place from exhaustion ; or the mental aberration may 
pass into chronic mania, or into a condition of slight mental 



DISTURBANCES OF INTELLECTION. 473 

impairment. Complete recovery occurs in about seventy per cent, 
of the cases. 

Under the name oi transitory frenzy is described asymptomatic 
affection which in the early hours of the attack might easily be 
confounded with acute mania, and which in some cases may really 
be an incipient peripheral cerebritis. It is defined by Spitzka 
as a condition of impaired consciousness characterized by either 
an intense maniacal fury or a confused hallucinatory delirium, 
whose duration does not exceed the period of a day or two. It 
will be seen at once from this definition that the only distinction 
which separates this alleged disease from acute mania on the one 
hand and acute cerebritis on the other is the rapid recovery. 
The symptoms also do not differ from those of an epileptic 
frenzy. The attack, however, differs from ordinary epileptic 
mania in occurring only once in the life of the individual. I do 
not think that transitory frenzy should be considered as a distinct 
affection, but only as an attack of acute violent mania, produced 
by unknown and probably varying causes. It would be, to my 
mind, just as rational to erect into distinct diseases the occasional 
epileptiform convulsions which occur without our being able to 
discover their cause, as to consider transitory frenzy a distinct 
affection. 

Chronic Mania may develop as the result of an acute mania, 
or may come gradually without a preceding stage of violence. 
It is a condition of general mental aberration characterized by 
the presence of varying or non-systematized delusions, and by a 
condition of exalted emotional excitement. In most cases the 
chronic maniac, although more or less disturbed intellectually all 
the time, suffers from irregular exacerbations, in which the con- 
dition of excitement may become extreme and the symptoms rise 
in severity until they resemble those of an original acute mania. 
During these paroxysms, and often indeed in the intermissions, 
there are incoherence of speech, lack of power of association of 
ideas, delusions, often increased activity of the perceptive facul- 
ties with hallucinations, and mental and physical excitement. 
The symptoms of chronic mania are similar to those of acute 
mania, but are less severe in type. They are also modified by 
the progressive failure in the intellectual power as the patients 



474 DIAGNOSTIC NEUROLOGY. 

drift towards dementia. The hallucinations and delusions are un- 
fixed, constantly changing, are not systematized, usually are con- 
formed to the emotional excitement of the patient, or, if they 
should take for the moment a depressive or disagreeable form, do 
not affect the mood of the individual. They may be concerning 
any conceivable person, thing, or place, or may take forms not 
reached by the most vivid imagination in its sane moments. The 
moral sense is completely altered or abolished : those to whom the 
individual had previously been attached become objects of hate; 
modesty there is none, the patient revelling in obscene speech and 
immodest gestures, and often suffering from sexual fury. Like 
acute mania, chronic mania varies greatly in its intensity: indeed, 
the mild form of mania known as hypomania is especially apt to 
pursue a slow course. Chronic mania not rarely changes into 
chronic melancholia; whether primary or secondary, it is of long 
duration. Occasionally recovered from, it usually terminates in 
from two to five years in dementia. 

Melancliolia. 

The connection between the depressive emotions and the health 
of the abdominal organs is too well recognized to need comment. 
There is a condition in which oxalate of calcium is found in the 
urine, associated with a great deal of emotional depression, some 
mental sluggishness, and a certain amount of bodily weakness, 
and occasionally, although not always, dyspeptic symptoms. This 
condition, which is known as oxcduriay is largely relieved and fre- 
quently cured by the free administration of nitro-muriatic acid, 
with an occasional purgative, especially if these remedies be aided 
by free exercise and abstinence from the use of sugar. These 
cases of oxaluria might be considered a mild form of melan- 
cholia, but, according to the studies of Dr. G. D. Stahley {Medical 
Neics, June 5, 1886), oxaluria occurs proportionally as frequently 
in other cases of insanity as it does in melancholia, and in melan- 
cholia it may at times be present and at times absent without 
change in the mental condition. It would appear, therefore, that 
there is no direct relationship between severe cases of melancholia 
and oxaluria. 

In fully-formed melancholia the basal condition is a profound 
emotional depression. In a proportion of cases of so-called mel- 



DISTURBANCES OF INTELLECTION. 475 

ancholia there is not a complete intellectual insanity, but merely 
an emotional depression. The patient fails to be interested in 
the life around him, not because he is incapable of understand- 
ing the problems of life, but because nothing but himself is of 
interest to him or occupies his thoughts. In the lighter deorees 
of the aflFection the patient will simply say that he is horribly 
depressed and cares for nothing. He sits all day in a chair, 
quiet, perhaps with the hands folded, seemingly thinking of 
nothing, with an expression of perfect indifference and apathy 
on his countenance. There is no interest in business, because the 
interest is all the time centred in himself. There is no interest 
in wife and family, not because the relations are not recognized, 
but because the man is absorbed in nursing the phantom spirit 
which oppresses him. 

When the symptoms are more active and severe, instead of 
simple apathy, there is wringing of the hands and perpetual 
moaning and lamentation, not for any definite reason that the 
patient can assign, but simply because of the depression of spirits. 
Under these circumstances it will be found that all his thoughts 
are tinctured with this emotional depression. If the man is a 
business-man, he sees nothing but ruin before him. If he has a 
conscience which is not void of offence, the memory of his past 
misdeeds, like a Nemesis, forever haunts him. If his children 
are ill, they are going to be swept away by death. The whole 
landscape is covered with a black cloud, which throws everything 
into the darkest shadow. Nevertheless, there may be even yet no 
intellectual delusions. When the patient is aroused he talks well 
and reasons well. If you can get him to forget himself for a 
moment, his intellectual actions are perfect. After a time delu- 
sions make their appearance. They are in typical cases always 
unsystematized. They usually develop gradually, and not rarely 
are the outcome of some real feeling which the patient has. They 
may exist with or without hallucinations. Both hallucinations 
and delusions always take the depressive type. Hallucinations 
of hearing are the most freqnent. The patient hears voices, but 
they are evil voices. Those who have committed murder have 
sometimes asserted that they had two voices in them, one cry- 
ing, " Kill ! kill V the other voice trying to restrain them. Men 
have held their hands in the fire until they were burnt black, 



476 DIAGNOSTIC NEUROLOGY. 

because they have heard voices telling them that it was better to 
enter into the next world maimed than to go with a whole hand 
guilty of blood or other offence. 

Sometimes hallucinations of sight occur; but these are less 
common than hallucinations of hearing. Troops of spirits from 
the other world pass before the patient, but it is never angels 
or spirits from heaven, but always sights of sorrow and of woe. 

Delusions of touch are rare, and delusions of smell are still 
more uncommon. I do not recall a case in which I have seen 
a patient with delusions of smell. They, however, are occasion- 
ally present. The melancholic never smell pleasant odors. It 
is always sulphurous vapors or horridly fetid exhalations that 
oppress them. 

There are certain varieties of melancholia which need brief 
mention. When there are no delusions the cases are sometimes 
spoken of as Simple Melancholia, as Melancholia without Delirium, 
or as Hypo-melancholia. In this form of melancholia, although 
the mind of the patient may be clear, suicidal and homicidal 
impulses are very frequent. 

Melancholia Agitata is that variety in which there is great ex- 
citement, the patient being continually on the move, rushing up 
and down, lamenting loudly, wringing the hands, tearing the hair, 
destroying his clothes, etc. The agitation may rise to the point 
of complete frenzy. The melancholic frenzy differs from that of 
mania in being founded upon a state of intense terror and fear. 
The patient assaults by-standers as a matter of self-defence against 
their supposed machinations or attacks. Homicide, suicide, and 
self-mutilation are very frequent during the outbreak of melan- 
cholic frenzy. 

Melancholia Attonita, or 3Ielancholy with Stupor, is the variety 
in which all the physical as well as the mental powers of the 
patient are overwhelmed by the emotional depression : he is, as 
it were, paralyzed and dumb under the power of his fear. Lying 
in bed with the eyes open, or more rarely closed, asking for no 
food, giving no heed to any personal desires, but living in a con- 
tinuous state of absolute wantlessness, he exists as an automaton. 
If taken up and dressed, he remains sitting in the same indifferent 
hopeless passivity. 

The physical condition in acute melancholia is always that of 



DISTURBANCES OF INTELLECTION. 477 

depression; the bowels are usually constipated, the breath is foul, 
the tongue heavily coated, the surface of the body cool, the pulse 
feeble, slow, or sometimes rapid, and the skin harsh. In the 
acute cases there is often rapid emaciation. 

In certain forms of cerebral syphilis with stupor the symptoms 
may for a time resemble those of melancholia attonita ; but the 
diagnosis can usually be made out by the history of continuous 
headache, or the presence of some evidence of a focal lesion. 

Melancholia may end in death, recovery, or terminal dementia, 
or may become essentially chronic. It is very unusual for it to 
last less than three months, and I have known it to last unchanged 
for many years, and then the patient rapidly recover. From fifty 
to sixty per cent, of the cases recover. Of all the varieties of 
melancholy, melancholia attonita is most apt to end in dementia. 

Katatonia. — A few years since, Dr. Kahlbaum, of Gorlitz, 
separated from melancholia, under the name of Katatonia, a class 
of cases which are now believed by many alienists to be distinct. 
The disease is defined by Spitzka as follows : 

" Katatonia is a form of insanity characterized by a pathetical 
emotional state and verbigeration, combined with a condition of 
motor tension. 

" The illness begins with an initial stage, resembling that of 
an ordinary melancholia. This is followed by a period in which 
the patient presents an almost cyclical alternation of atony, ex- 
citement of a peculiar type, confusion and depression, which finally 
merges into a state of mental weakness approaching, if not reach- 
ing, the degree of a terminal dementia. Any single one of these 
enumerated phases may be absent. 

" The excited stage presents symptoms of a kind different from 
those of ordinary melancholia, and constitutes a connecting link, 
as it were, between the symptoms of an agitated melancholiac 
and those of a lunatic with fixed delusions. Some of the patients 
present exaggerated, others diminished, self-esteem, and not rarely 
does the developing delirium assume an expansive tinge. But 
all katatonics exhibit a peculiar pathos, either in the direction of 
declamatory gestures and theatrical behavior, or of an ecstatic 
religious exaltation. Frequently the patients wander about, imi- 
tating great actors or preachers, and often express a desire and 
take steps to become such preachers and actors.^^ 



478 DIAGNOSTIC NEUROLOGY. 

The hallucinatiODS of katatonia are always depressive and 
accompanied by a melancholic depression of spirits, which is 
said, however, never to be so painful as in melancholia. Severe 
occipital headache and cataleptoid attacks are asserted to be char- 
acteristic. The cataleptoid condition is typical and extreme, the 
patient remaining for long periods corpse-like and immobile. I 
have seen two cases which perhaps ought to be classed as kata- 
tonia. Whilst under observation there was no headache and no 
period of excitement; but the cataleptoid condition was very 
marked. For hours the patient would remain standing or sitting, 
perfectly immobile in whatever position he might be placed. 
Certain forms of melancholia attonita resemble katatonic insanity, 
and I do not see how the diagnosis could be made between melan- 
cholia attonita and a katatonia from which the stage of excite- 
ment was wanting. Masturbation is alleged to be very frequent 
in katatonia, and was markedly present in one of my cases. It 
is, however, very common in all classes of mental weakness ap- 
proaching dementia. 

Mental Deteriorations, 

In its fullest development dementia is that condition in which 
all the higher cerebral functions are abolished, so that neither 
thought nor emotion remains, and the individual, reduced to an au- 
tomaton, simply eats when fed, and breathes when air is presented 
to him. The animal functions go on uncontrolled by the will, 
the bladder and rectum are evacuated when full, or if, as is often 
the case, the general nervous power is reduced to a minimum, 
the urine and faeces dribble over when their natural receptacles 
are full, — the perpetual dropping of urine indicating a distended 
bladder, and a constant passing of small quantities of faeces a 
distended rectum. 

The approach to dementia is usually gradual, and death often 
occurs before the lowest degradation is reached, so that in the 
majority of cases more or less mental activity exists. The emo- 
tions are apt to survive the intellectual faculties, and, unchecked 
by the will, whose power is gone, may even be unduly active. 
Irritable, brutal, more unreasoning and hence more unreasonable 
than a brute^ the dement may be a most dangerous lunatic. Not 



DISTURBANCES OF INTELLECTION. 479 

rarely^ however, gentle, easily led, because without capability of 
intellectual persistence, he lives a childish existence. 

In absolute dementia there are no grades, but the gradual courses 
of nature and the necessities of discussion have caused the term 
to be widened in its use, until now it is employed to signify 
simply any mental defect which is so serious as to paralyze the 
thinking ability of the individual. 

A dementia w^iich has been congenital or has developed in 
infancy is usually spoken of as imbecility or idiocy. It is gener- 
ally due to original lack of brain-development, and is, therefore, 
scarcely the result of disease, and I shall say no more about it in 
this book. 

Dementias due to mental disease are either primary or ter- 
minal: a primary dementia is one that has developed without 
obvious previous mental disease; a terminal or consecutive de- 
mentia is one that follows an attack of insanity. 

Primary Dementia. — Primary dementia is a condition grad- 
ually, rapidly, or suddenly developed, in which there is suspen- 
sion or great impairment of the mental powers without distinct 
emotional disturbances. There are included under it cases which 
differ greatly in the cause of the dementia, as well as in the degree 
of the mental impairment and in the ultimate results. 

For our present purposes these various cases of primary de- 
mentia are divisible into those in which the dementia is connected 
with obvious organic brain-disease, — ix,, Organic Dementias ; 
those in which it is connected with general developmental changes 
of the body, such as puberty and old age, — i.e.. Developmental 
Dementias; and those which do not belong to either of these two 
classes, — ix.^ Miscellaneous Dementias. 

Organic Dementias. — In dementia of this class the memory 
almost invariably suffers earlier and more severely than the other 
mental faculties. There is, however, nothing in the dementia 
itself suflBciently characteristic to enable us to recognize its eti- 
ology. The diagnosis is to be made out by noting the various 
symptoms, other than mental, which indicate organic brain-disease. 
When there is severe headache, an organic dementia is usually the 
result of chronic meningitis, brain-tumor or abscess, or brain- 
syphilis; when headache is not present, the disease is ordinarily 
general paralysis or its syphilitic counterfeit. 



480 DIAGNOSTIC NEUROLOGY. 

Developmental Dementias. — In this class I propose to con- 
sider two mental deteriorations, — Senile Dementia, and Hebe- 
phrenia, which respectively are associated with old age and 
puberty. 

In some cases of old age the mental faculties are preserved 
almost intact amidst the general physical wreck, but more fre- 
quently the intellectual powers undergo deterioration, which may 
even exceed in extent that of the muscular strength. To this con- 
dition the name of Senile Dementia is commonly given. The mental 
enfeeblement is sometimes accompanied by emotional disturbances 
which warrant our speaking of the patient as suflFering from senile 
melancholia or senile jnania, as the case may be. Delusions are 
very frequently present, even when the emotional disturbance is 
not marked. These delusions may take the ambitious form, but 
usually are depressive. According to Spitzka, they are almost 
always unsystematized, but I have certainly seen them very thor- 
oughly systematized. Frequently some master-passion of the indi- 
vidual seems in old age to increase rather than lose in force, until 
at last it dominates the whole character, a result which is greatly 
facilitated by the gradual weakening of the will. Not rarely a 
moral change occurs : he who has been during life chaste and re- 
fined becomes coarse and filthy in language as in person. A pecu- 
liar sexual excitement is on occasions present, giving rise to "senile 
satyriasis," which may lead to indecent assaults, but more frequently 
is manifested in the contraction of absurd or incongruous marriages. 
Delusions of persecution are very frequent, and the subject may live 
in perpetual fear. Senile dementia develops gradually, and a 
recognition of its earlier stages is frequently a matter of the great- 
est importance when there is no emotional disturbance. The first 
symptoms of important change are usually a loss of memory for 
recent events, with a loss of power of perceiving the relative im- 
portance of things and affairs. So long as the memory is fairly 
preserved and sufficient intellectual balance exists for the proper 
weighing of events, the medical expert should be very slow in 
deciding that the aged person is legally incompetent unless dis- 
tinct delusions exist. It must, however, be borne in mind that 
the weakening of the will and the perversion or increase of some 
of the emotions render the aged especially liable to be improperly 
controlled by designing persons. 



DISTURBANCES OF INTELLECTION. 481 

Hebephrenia, or Insanity of Pubescence, is defined by Spitzka as 
characterized ^^by mental enfeeblement marked by a silly dispo- 
sition, following a preliminary period of depression, which has 
the same tinge as, without the depth of, that characterizing that 
of melancholia, and which coincides with or follows the period 
of puberty/^ 

This form of intellectual aberration might very well be classed 
as a variety of melancholia, but I have preferred to put it in this 
place because in the cases that I have seen the emotional state 
has been one of indifference and apathy rather tlian of acute de- 
pression. 

The psychosis may develop gradually or slowly. There is a 
condition of restlessness and disinclination to mental labor, com- 
bined with a line of conduct best described as silly. There is 
usually a distinct alteration of character. Rapid emotional changes 
resembling those which are so frequent in hysterical subjects some- 
times take place. Paying no attention to business, abandoning 
lucrative pursuits, or wandering from position to position, with a 
constantly-increasing egotism and even a peculiar sentimentality, 
the subject of hebephrenia slowly loses mental power. Even at 
this stage sudden furious maniacal outbreaks occur, and when the 
loss of mental power becomes extreme these outbreaks are more 
frequent. Hebephrenia in the majority of cases, if not in all, 
rests upon a foundation of originally faulty nervous organization, 
and is, therefore, a protracted psychosis, which is rarely, if ever, 
completely recovered from. It may pass rapidly into a terminal 
dementia, or the patient may long remain in a condition of marked 
mental enfeeblement. A few cases occur in which permanent im- 
provement has followed treatment. In a large proportion of cases 
hebephrenia is connected with excessive masturbation : hence by 
some writers the insanity is spoken of as the Insanity of Mastur- 
bation, 

Miscellaneous Dementia. — In this division are included three 
classes of cases,— Dementia of Shock, Confusional Insanity, and 
Stuporous Insanity. 

Dementia of Cerebral 5/ioc/:.— There are various recorder] cases 
in which a sudden emotional excitement has produced complete 
loss of the intellectual faculties: as in a case recorded by Buck- 
nill and Tuke, in which a young lady of refinement and edu- 

31 



482 DIAGNOSTIC NEUROLOGY. 

cation was assaulted and raped by a band of ruffians and became 
at once a speechless idiot for life. In a second case a young lady 
having by mistake fatally poisoned her father, from the time 
of his death " was lost to all knowledge or notice of persons and 
occurrences around : food she never took except when it was 
placed upon her tongue: the only sound which escaped her lips 
was a faint yes or no.'' 

Primary Confusional Insanity is a form of mental aberration 
in which there is confusion of ideas and marked incoherence of 
speech without decided emotional disturbance. This condition 
may develop acutely as the result of an emotional shock, or of a 
cerebral overstrain, or of an exhausting disease, and may be 
looked upon as a milder form of dementia of cerebral shock. It 
seems to be a simple condition of intellectual exhaustion. It may 
develop immediately after the strain, or there may be a few days 
of incubation. Hallucinations and delusions unstable and even 
contradictory in character are frequent. The memory may be 
affected so that the patient does not recognize old acquaintances or 
familiar places. Delusions of identity are stated by Spitzka to 
be very frequent. According to the same authority, the speech 
affords the most characteristic symptom, the sentences being left 
incomplete because the subject is unable to follow an idea to its 
completion. Thus, a patient said to Dr. Spitzka, "I am I — I 
don't know that — I — is dead — funerals are — how do you do — 
met you in Boston steamer — this is London — London — I am sure 
of it — see! I have not forgotten everything — there are not so 
many now." 

Stuporous Insanity, Acute or Primary Dementia of many Eng- 
lish writers, Primary Curable Dementia of some German writers, 
is an affection which usually comes on in young adults, and which 
so closely simulates melancholia attonita in its symptoms that it 
is scarcely to be distinguished from it. There is, however, no 
distinct emotional disturbance ; but if the apathy be extreme it 
may be impossible to determine the existence or non-existence 
of depressive emotions, and I believe that the two mental states 
grade into each other. The symptoms may come on gradually or 
suddenly. At the height of the attack the patient is immobile, 
insensitive, absolutely apathetic, sitting or lying as placed, with 
no wants and apparently no perception of surrounding objects. 



DISTURBANCES OF IXTELLECTION. 483 

In some cases this condition becomes so extreme that even the re- 
flexes are affected^ and in feeding the patient it is necessary to put 
the food well back into the pharynx. The same lack of energy 
is shown in all the involuntary muscles : the heart's action is slow 
and feeble ; the bowels are obstinately constipated ; the extremi- 
ties are cold, and the feet oedematous, as the result of vaso-motor 
weakness. The urine is rich in phosphates, and the physiological 
discharges of the skin and uterus are suppressed. I have seen 
symptoms exactly resembling those of stuporous insanity as laid 
down in the books produced by gouty atheroma of the cerebral 
vessels (see page 458), and similar cases have been described 
by Voisin. In dementia depending upon disease of the cere- 
bral vessels recovery rarely, if ever, occurs. Stuporous insanity 
has been produced by emotional shock, excessive overwork, and 
various causes of exhaustion, such as starvation, profuse hemor- 
rhage, or exhausting discharges. It is also not rarely closely con- 
nected with excessive masturbation. It seems to me, therefore, 
that we can scarcely consider it to be other than an intense degree 
of the so-called primary confusional insanity. The prognosis is 
stated to be highly favorable, ninety per cent, of the patients 
recovering in a period of time which varies from three weeks to 
three or four months. The prognosis is less favorable when there 
is excessive masturbation. 

Terminal Dementia. — Almost any form of active insanity may 
be followed by a stage in which the mind is so far lost that even 
the distinctive characteristics of the original insanity have more or 
less completely disappeared. This state is the so-called secondary 
or terminal dementia. The completeness of the mental ruin varies : 
in some cases, apathetic, mindless, without thought or emotion, the 
individual lives on, a mute, almost motionless, vegetating autom- 
aton ; in other instances, restless, full of obtrusive or destructive 
activity, noisy, with incoherent talk, the dement,, although over- 
flowing with animal spirits, and perhaps, also, possessed by a 
peculiar aggressive egotism, is useless for any purpose, — mayhap 
is almost uncontrollable and exceedingly troublesome. Sometimes 
the mental condition is simply that of weak-mindedness, and the 
harmless imbecile seems like an overgrown child. Not rarely a 
little intellectual power remains; and if with this there be docility, 
the dement may be usefully employed about a farm, in the wards 



484 DIAGNOSTIC NEUROLOGY. 

of a hospital, or in other situations in which he can be carefully 
watched over and constantly directed and taken care of. 

PERIODIC INSANITIES. 

Periodic insanities are naturally divided into those in which the 
attacks take the form of mania; those in which they are melan- 
cholic; and those in which mania and melancholia alternate in 
regular cycles. These forms are respectively known as Periodic 
Mania, Periodic Melancholia, and Circular Insanity. 

The attacks of Periodic Mania often begin abruptly, but may 
be preceded by prodromes, such as emotional depression, vertigo, 
neuralgia, etc. During tlie active stage there are hallucinations, 
delusions, violent excitement, furious outbursts of anger, and a 
pronounced tendency to impulsive actions, such as causeless as- 
saults, indecent exposure of person, attempts to rape, etc. : in a 
Avord, the symptoms of the active stage do not differ from those 
of ordinary acute mania. 

The attacks of Periodic Melancholia are similar to those of 
ordinary melancholia, with a pronounced tendency to impulsive 
acts, especially to suicide. 

In Circular Insanity, or Cyclothymia^ the cycles vary in length 
from a few days to many months : as a general rule, the more 
violent the symptoms the shorter is the time required to complete 
a cycle. The arrangement of the cycle varies in different indi- 
viduals, but is constant in the same case. In this way a melan- 
cholia may be followed by a mania, and this by a lucid interval, 
or the mania may first appear, or the lucid interval may follow 
the melancholia. The passage from one mental condition to 
another may be abrupt, but more commonly it is gradual. The 
mania may be violent, resembling in all its symptoms an attack 
of ordinary acute mania. It may be mild, or it may even simply 
amount to a condition of mental exaltation, in which the sub- 
ject is dominated by all sorts of immoral impulses and tendencies, 
which lead to a line of conduct that has been aptly spoken of as 
insanity of action. In like manner the melancholia varies in 
intensity from the most profound, hopeless, despairing apathy to 
a slight depression of spirits. Sometimes the lucid interval is 
wanting, and mania follows melancholia and melancholia follows 
mania in perpetually-recurring alternation. These cases constitute 



DISTURBANCES OF INTELLECTION. 485 

the folic circulaire of Falret. There are certain cases in which 
the symptoms of a circular insanity are so slight that the patient 
does not at any time, to the eye of the ordinary observer, overstep 
the bounds of sanity. Such individuals are avoided by their 
friends as moody and unreasonable : to-day sanguine, talkative, 
energetic, and extravagant, to-morrow they are taciturn, apathetic, 
or full of vain regrets for acts that they have done or enterprises 
that they have entered upon while in the condition of exaltation. 

In most cases of periodic insanity the patient during the lucid 
interval will reveal to the experienced observer evidences of ab- 
normal mental action. Sexual perversion, morbid fears and morbid 
impulses, excessive excitability, moral degradation, sexual excesses, 
loss of self-control, inordinate development of avarice, jealousy, or 
other passion, — these are among the most common manifestations 
of cerebral aberration during the lucid period's of periodic insanity. 
According to Spitzka, kleptomania is commonly a symptom of the 
lucid intervals of a periodic insanity. 

Periodic insanity rests upon an original faulty organization of 
the nervous system, and is generally hopeless. In these respects 
it is closely related to the partial insanities. When the lucid in- 
tervals are long and with marked mental irregularities, the disorder 
might well be classified as a partial insanity with regular exacer- 
bations. 

INCOMPLETE INSANITY. 

Partial Insanity, Reasoning Mania, Mania without JDelvnum, 
Monomania, Mania of Character, — These terms have been em- 
ployed by various writers to designate a large class of chronio 
insanities in which the insane condition is limited, at least in its 
marked manifestations, to certain portions of the brain-functions. 
The best scientific definition of monomania that I know of is that 
given by Spitzka. He says, " Monomania is a chronic form of 
insanity, based on an acquired or transmitted neuro-degenerative 
taint, and manifesting itself in anomalies of the concei)tional 
sphere,— i.6., the sphere of thought,— which, while it does not de- 
stroy entirely the mental mechanism, dominates it.^' This defini- 
tion is, I think, scarcely wide enough. I believe that the term 
monomania should include not only those cases in which the intel- 
lectual or conceptional sphere is involved, but also those in which 
the emotional condition is affected. Avarice, envy, vanity, and 



486 DIAGNOSTIC NEUROLOGY. 

other passions are as much cerebral functions as is the reasoning 
power itself. There are cases in which these emotions become so 
magnified in their power that they dominate the whole individual. 
As an example may be taken the miser, in whom avarice has 
grown until it has entirely subjugated the ego, so that the man 
perishes of hunger, gloating upon the useless gold which he 
clutches in his hand. 

The cases of partial insanity naturally group themselves into 
two classes : in the first of these are comprised those cases in 
which the delusions are distinct and apparent; in the second are 
included cases in which the delusions are altogether wanting or 
are very obscure, the insanity l)eing confined chiefly or altogether 
to the emotional and moral sphere. The second of these groups 
constitutes the mania of character of Pinel. 

The following quotation from Morel (quoted by Hammond, 
Treatise on Insanity, p. »>65) portrays very well subjects of the 
mania of character, or moral insanity : 

^^Some have great pride and ambition, and consider themselves 
as being destined to the performance of acts of momentous im- 
portance. No consequence, however absurd, to which their in- 
sanity leads them, shakes their confidence in themselves. Others 
are impelled by bad tendencies to the perpetration of the most 
extravagant or monstrous acts. They rebel against all family 
or social obligations and duties, and are constantly considering 
themselves the victims of misunderstanding or injustice. For the 
persecution of which they imagine themselves the subjects they 
seek to avenge themselves on their relations, their friends, and 
the world at large by making a parade of their immoral con- 
duct, thinking to compromise the interests of those who ought 
to be dear to them by the shameful exhibition of their depravity. 
They go into the streets and other public places in a filthy and 
ragged condition. They let their hair grow, and endeavor to 
attract attention by all kinds of ridiculous and improper acts. 
Others apply their brilliant intellectual faculties, notwithstanding 
they are marked by an irregularity and incoherence of action, to 
the production of literary works of which the extent and the 
plan exceed the limit that it is possible for human power to reach- 
These works are often in their teachings contrary to public moral- 
ity and feeling. They are dreamers, Utopians, false guides, who 



DISTURBANCES OF IXTELLECTIOX. 487 

in their mental conceptions and in the results of their intellicrence 
and imagination exhibit the same eccentricity, the same sharae- 
lessness, as in their acts/^ 

In all cases of mania of character there is a mental inability to 
weigh evidence that conflicts with the dictates of the ruling pas- 
sion, which almost amounts to an intellectual insanity. In the 
great majority of cases sooner or later delusions will appear, 
although careful search may be required to detect them. As an 
example of such a case the following history is in point. Several 
years ago I was called to a palatial mansion, and was met in a 
boudoir by a handsome young woman, perfectly lady-like and 
self-restrained in her manner. She said to me, " Doctor, I have 
sent for you under very painful circumstances, because I feel that 
I must confide in some one.^^ She then went on to say that she 
had syphilis, that this had been given to her by her husband, 
and that she had had a child born in a certain watering-place, 
which had died of hereditary syphilis. She further told me in 
detail of having personally detected her husband's infidelities. I 
examined the woman thoroughly, but could not find the slightest 
evidence of specific disease. I finally wrote to the physician who 
had attended the woman at the birth of the child. He at once 
replied that the child was well formed and perfect, and that it had 
died of an ordinary acute infantile disease. I then assured the 
woman that she had not had syphilis. She expressed herself as 
much relieved, but was unrelenting towards her husband, who she 
said kept a mistress, and frequently annoyed her by communi- 
cating with said mistress at places of amusement to which he had 
taken herself, and by having said mistress to drive immediately 
behind them in the Park. She had detectives employed to watch 
her husband, and had a well-known lawyer engaged to super- 
intend the detectives. At first I entirely believed the woman's 
story ; but after some weeks I began to suspect that there was 
something wrong with her brain, and to watch her. 

To make a long story short, my patient watched her husband 
more and more closely, at an expense of hundreds of dollars, and 
at last one night at a theatre pointed out as his paramour a 
lady who was well known and entirely beyond suspicion. The 
whole of her story was undoubtedly invented, although she her- 
self believed it, and for a time even misled me into crediting it. 



488 DIAGNOSTIC NEUROLOGY. 

Her husband, however, believed that she was full of the devil and 
wanted to torment him, and never could be persuaded that she 
was insane. She was all the time acting against her own interest. 
Her husband was a man of great wealth and natural kindliness, 
dotingly fond of her, and would have granted her utmost wish if 
she had acted in a decent manner towards him. 

Her intellectual powers, except in regard to her husband's in- 
fidelities, were perfect. She mingled in society, reasoned well, 
and did everything well, but she had this delusion. I found in 
this case, as is found in most cases of monomania, that clear back 
to childhood there had been evidences of something not quite 
right with the cerebral functions. The woman had always been 
extremely vain, wildly ambitious to shine in fashionable society, 
and excessively egotistical, — characteristics which frequently pre- 
cede the evidences of monomania, as was well exemplified in the 
history of Guiteau. 

Although Esquirol used the term monomania as belonging to 
those cases in which there is an excess of animal spirits and of 
the emotions, such as ambition and anger, which are related to 
aggressiveness and power, there can be no doubt that there are 
two distinct classes of monomaniacal persons, — those in whom 
there is a condition of emotional exaltation, and those in whom 
there is a condition of emotional depression, corresponding to 
the mania and melancholia of general insanity. 

The delusions of monomania, like the delusions of general in- 
sanity, conform in type to the emotional state, and often grow out 
of something having a real existence. A melancholic or hypo- 
chondriacal monomaniac may have some bad feeling, which is in- 
creased in his mind until it dominates his whole life: thus, a dys- 
peptic symptom leads him to the belief that he has no stomach. 
These cases are to be distinguished from the cases of hypochon- 
driacal melancholia by the fact that the delusion is "systematized," 
— i.e., it is one about which the patient reasons, and which he 
defends; but, as has already been stated, the systematized delusion 
grades into the unsystematized, and hence cases of monomania 
grade into cases of chronic mania or chronic melancholia. 

On the other hand, the line between monomaniacal insanity and 
sanity is an entirely arbitrary one, and cannot be fixed by any 
finite power. As is well known, the children of insane persons 



DISTURBANCES OF I^'TELLECTIO^^ 489 

are very apt to be more or less different from ordinary human 
beings. Although they perform all the duties of life, their men- 
tal or normal organization seems to be lacking in something, or 
to have suffered some twist. Perverse, drifting almost of neces- 
sity into criminal acts, eccentric, such unfortunates are a long 
series of human atoms whose faulty brain-organization separates 
them from their more fortunate fellows. When this separation is 
suflSciently wide, when the mental organization is so bad that 
every one can perceive that the man is the victim of his own im- 
perfectly-developed brain, he is said to be insane. But when the 
unfortunate individual is a little more like the normal human 
being, he is looked upon simply as eccentric, perverse, or wicked, 
and, unloved and unpitied, drifts through life sometimes to pov- 
erty, sometimes to the hospital, sometimes to the jail, and, it may 
be, to the hangman^s scaffold. Sanity, insanity, criminality, power 
over self, free will, mental attributes, these and similar terms are 
household words with all of us, but no man knows whence they 
come, or what they are, or how far the individual is master of 
himself or is driven by the hand of fate, as represented in the 
physical conformation of the nerve-cells and fibres of his brain. 

As has already been insisted upon, insanity is not a disease or 
a distinct entity. Xecessity for an arbitrary line between sanity 
and insanity is not of scientific but of legal origin, and when the 
medical expert affirms that he is unable to measure out accurately 
the exact degree of human responsibility he simply acknowledges 
that he himself is a finite being, and that the problems of life 
baffle his utmost thought. It has been reserved for judges upon 
the bench and lawyers at the bar to arrogate to themselves the 
attribute of infinity, whilst ministers of the gospel but too often 
teach that the last and highest revelation of a merciful God is 
that this poor, broken humanity, helpless so often in the iron grip 
of its own perverse nature, shall be punished by flames eternal. 

The difficulty of drawing a line between sanity and insanity is 
well illustrated by religious monomaniacs. Are those who believe 
that they habitually hold communion with spirits, the dupes of 
modern spiritualism, to be considered insane? Is the woman 
who is convinced that Providence has as the result of her prayers 
put back the ordinary course of nature and relieved her of an in- 
curable affection, sane or insane ? In matters of religious belief, 



490 DIAGNOSTIC NEUROLOGY. 

every man who holds strongly to a certain faith might consider 
every person who believes in a different faith to be insane. Pro- 
found belief in the daily presence of spirits and in the utmost 
vagaries of modern spiritualism may coexist with great scientific 
or business acumen. 

Although it seems impossible to fix a line which shall separate 
a sane from an insane religious trust or belief, it can hardly be 
doubted that many of the devotees of spiritualism must be con- 
sidered as across the line. To illustrate how closely monomania 
is related to sanity, and how difficult it sometimes is to draw 
the line, I may cite the case of a superior officer of the United 
States army, now dead, who was, at the time I speak of, stationed 
at one of the frontier posts of the country, and was performing, 
with satisfaction to all, the duties appertaining to his rank. One 
day he said to a friend, '^ My life in this frontier post, from its 
monotony, would be absolutely insupportable if it were not for 
my daily mail which I get from my dead friends. I had a letter 
from your brother last week, and every morning I live in expec- 
tation of receiving a letter from some deceased friend or relative.^* 
He was asked how the letters came, and it was learned that they 
were received through a certain living medium in the eastern part 
of the United States. This woman, no doubt receiving a stipend 
from the officer, would almost daily write him a letter, which was 
received by him with absolute credence as coming through her 
from the spirit-world. On another occasion he said, " There is 
one thing that gives me great comfort, and that is that I am a 
descendant of the Virgin Mary." Some one intimating a doubt 
of that genealogy, he continued, "I know that I am a descend- 
ant of the Virgin Mary, because I had a letter from her, and she 
says so; and she certainly ought to know." Can we hesitate in 
deciding that here was a delusion which was thoroughly system- 
atized and logically defended by its holder? The first premise, 
that he received letters from the spirits, was false, but his reason- 
ing based upon it was sound. 

Not only is it difficult to draw the line between sanity and 
insanity, but there is a close relation between partial insanity 
and high intellectual power, especially with reference to genius 
or the power of original thought. There can be no doubt that 
a proportion of those who are considered as the most pronounced 



DISTURBANCES OF INTELLECTIOX. 491 

examples of genius are men whose intellects are on the border 
of insanity. To say that an individual is a genius usually means 
that he has a certain function of the mind exalted high above 
the other functions. A man whose imagination is developed 
out of proportion to his reasoning faculties is apt to be a poet 
or a novelist, and produces works which may live through cen- 
turies. Such a man is above his fellows, not by virtue of great 
brain-power, but because his brain takes a peculiar limited direc- 
tion. A genius is recognized as a man not practical. By a man 
not practical is meant one lacking in common sense ; and common 
sense is, after all, neither more nor less than the term used to ex- 
press good judgment in the ordinary matters of life. A man who 
has great imagination usually lacks reasoning power, and is not 
practical, because of his great imagination. One of the best ex- 
amples of the relation between extraordinary imaginative power 
and monomania is John Bunyan, the author of " The Pilgrim's 
Progress,^^ which, according to any standard that we have a right 
to set up, is one of the five or six greatest books in the English 
language. It is certainly more read than any other book with 
the exception of the Bible. No one who reads the history of 
Bunyan^s life can doubt for a moment that he for a long time 
suffered from monomania with depressing delusions, and his 
immortal dream may have been to him, at least at times, much 
more than a dream. 

Space is wanting to do more than call attention to the over- 
weening egotism of Byron and to the agonies of mental depression 
which overshadowed the life of Cowper; but I cannot forbear 
citing at greater length the case of Victor Hugo as illustrating 
the close relationship between insanity and genius. His uncle 
died insane ; his brother, Charles Hugo, in his late boyhood gave 
promise of remarkable talent for literature, but before twenty he 
became insane, and finally he passed into a condition of complete 
dementia. One of the daughters of Victor Hugo is now and has 
been for many years living in an insane asylum. According to 
the London Medical Times, there are in many of Hugo's finest 
productions numerous passages which could have been conceived 
only by a diseased imagination, and which are indelibly stamped 
with niiadness. A remarkable fact in the mental history of the 
great French poet is that along with his extraordinary iraagina- 



492 DIAGNOSTIC NEUROLOGY. 

tion there was a shrewdness almost as great. No banker could 
have more carefully managed his fortune ; no politician could have 
more tenderly nursed his popularity. He who had amassed over 
a million of dollars died the idol of a communistic democracy ; he 
who had played at fast and loose with all political parties was 
buried amidst a tumult of universal sorrow. 

The prognosis in monomania is exceedingly unfavorable. This 
is because the condition is so often the result of a faulty formation 
of some part of the brain. There is a peculiarity of the cerebral 
organization which shows itself from the very first. Only a small 
proportion of cases recover entirely. 



INDEX. 



A. 

Abdominal reflex, 181. 
Abducens Derve, 8Q. 

paralysis of, 32.6. 
Abnormalities of the optic disk, 331. 
Abrupt cerebral hemiplegia, 36. 

paraplegia, 49. 
Abulia, definition of, 421. 
Accidents of sleep, 414. 
Acetonaemia, see Toxaemic Sleep. 
Acute central myelitis, 53. 

delirium, see Acute Periencephalitis. 

mania, 471. 

periencephalitis, 450. 

peripheral encephalitis, see Perien- 
cephalitis, 
-^sthesiometer, 253. 
Affections, non-specific stuporous, 406. 

specific stuporous, 408. 
African sleeping disease, see Nelavan. 
Agrammatisma, 362. 
Akataphasia, see Agrammatisma. 
Alcoholic epilepsy, 117. 

headache, 304. 

insanity, 467. 

mental disorders, 465. 

paralysis, 27. 

spinal paralysis, 60. 
Amaurosis, 345. 
Amblyopia, organic, 345. 

toxaemic, 346. 
Amnesia, 360. 
Amnesic aphasia, 361. 
Amyotrophic lateral sclerosis, 67. 
Anaemia, spinal, 62. 
Anaemic headache, 308. 

sphacelus, see Raynaud's Disease. 
Anaesthesia, bladder, 256. 

cutaneous, 256. 

dolorosa, 56. 

gouty, 267. 

hysterical, 257. 

diagnosis of, 263. 

of throat, 255. 

organic, 265. 

general, 266. 
local, 274. 

psychic, 264. 

rectal, 255. 

vaginal, 256. 

visceral, 255. 
Anatomy of the cortex, 69. 

of the optic tract, 344. 

of the spinal cord, 46. 



Animal chorea, 154. 
Ankle-clonus, 182. 

effect of disease on, 192. 
Anterior crural nerve, 93. 

spinal artery, temporary arrest of cir- 
culation in, 30. 

thoracic nerves, 91. 
AphEemia, definition of, 359. 
Aphasia, 359. 

amnesic, 361. 

ataxic, 360. 

functional, 363. 

hemiplegia with, 39. 

lesions of, 364. 
Aphonia, definition of, 359. 
Apoplexy, 383. 

congestive, 383. 

spinal, 49. 
Argyll-Robertson pupil, 337, 339. 
Arsenical poisoning, 242. 
Artery, anterior spinal, temporary arrest 
of circulation in, 30. 

basilar, arrest of circulation in 
branches of, 30. 

posterior cerebellar, temporary ar- 
rest of circulation in, 30. 

vertebral, embolus in, 31. 
thrombus in, 31. 
Arthropathies, hemiplegic, 227. 

spinal, 228. 
Ascending paralysis, 28, 49, 51. 

lesions of, 53. 
Associated paralysis of the eye, 329. 
Assumed paralysis, 25. 
Ataxic aphasia, 360. 

gait, 196. 
Athetosis, 102. 
Atrophy by propagation, 81. 

joint, 82. 

local, 81. 

of the optic papilla, 335. 

progressive muscular, 83. 

reflex, 81. 
Aural vertigo, 209. 
Automatic consciousness, 100. 

movements, 97, 175. 
Automatism, psychical, 177. 



B. 



Basilar artery, arrest of circulation ii 

branches of, 30. 
Bell's disease, see Acute Periencephalitis, 
paralysis, 87. 

493 



494 



INDEX. 



Bladder anaBSthesia, 256. 

Blepharospasm, 137. 

Brain, organic disease of the, 112. 

tumor, 406. 
Breast, hysterical, 282. 
Bulbar general paralysis, 30. 

hemianaesthesia, 268. 

paralysis, inflammatory, 31. 
sensation in, 31. 



C. 

Caffeinic headache, 305. 

Cardiac and pulmonic headache, 306. 

crisis, 300. 

epilepsy, 111. 

vertigo, 204. 
Catalepsy, 394. 
Central myelitis, acute, 53. 
subacute, 64. 

nervous diseases, trophic bone- 
changes in, 226. 
Cerebellar affections, 198. 

disease, gait in, 198. 

titubation, 198. 
Cerebral contractures, 167. 

cortex, motor fibres of, 37. 

general paralysis, 29. 

hemianaesthesia, 270. 

hemiplegia, 35. 
abrupt, 36. 

hemorrhage, convulsions from, 115. 

mono})legia, 72. 
abrupt, 72. 
progressive, 72. 

multiple paralysis, 75. 

sclerosis, 456, 

shock, dementia of, 481. 
Cerebro-spinal meningitis, 449. 

sclerosis, multiple, 144. 
Cervical pachymeningitis, 63. 
Chin-jerk, sec Jaw-Jerk. 
Choked disk, 331. 
Chorea, 146. 

electric, 159. 

general, 148. 

hysterical, 159. 

in internal inflammations, 166. 

major, 97, 175. 

nature and limitations of, 151. 

of pregnancy, 158. 

of stump, 164. 

paralytic, 160. 

post-hemiplegic, 161. 

post-paralytic, 161. 

pre-hemiplegic, 160. 

reflex, 152. 
Choreas, local, 160. 
Choreic movement, 97. 
Chronic mania, 473. 

myelitis, 65. 

paraplegia, 65. 

peripheral paralysis, 83. 
Circular insanity, 484. 
Clot, diagnosis of position of, 37. 



Columns of Goll, 47. 

of Turck, 47. 
Coma, definition of, 379. 

foudroyant, 408. 

syphilitic, 408. 
Complete insanities, 470. 

non-periodic insanity, 470. 
Complicating insanities, 443. 
Congestive apoplexy, 383. 

headache, 308. 
Conjugated deviation of head and eyes, 

329. 
Consciousness, automatic, 100. 

disorders of, 357, 377. 

double, 371. 

sudden loss of, 379. 
Contraction of the field of yision, 353. 
Contractures, 166. 

cerebral, 167. 

hysterical, 169. 

in infantile paralysis, 168. 

of neuritis, 169. 
Convulsion, epileptiform, 97. 

hysteroidal, characteristics of, 102. 
Convulsions, 96, 97. 

from cerebral hemorrhage, 116. 

hysteroidal, 100, 120. 

in fever, 117. 

of childhood, 109. 

temperature as an aid to diagnosis in, 
121. 

tetanic, 102, 122. 

uraimic, 118. 
Co-ordination, causes of loss of, 196. 

disturbance of, 194. 

loss of, as a complicating symptom, 
198. 
Corpus striatum general paralysis, tee 
Lenticular General Paralysis, 
lesion of, 38. 
Correlated disorders of memory and con- 
sciousness, 369. 
Cortex, anatomy of the, 69, 
Cortical spasms, 134. 
Cough, nervous, 130. 
Cranial reflex, 182. 
Cremaster reflex, 181. 
Crossed oculo-motor palsy, 41. 

paralysis, 40. 

pyramidal tracts, 47. 
Crutch-palsy, 73. 
Cutaneous anaesthesia, 256. 
Cyclothymia, «ee Circular Insanity. 



D. 

Dead finger, 8ee Raynaud's Disease. 
Decubitus, 213. 
Deep reflexes, 182. 
Delirium. 438. 

grave, see Acute Periencephalitis. 

of grandeur, see Expansive Delusions. 

tremens, 465. 
Delusion, 427. 

systematized, 432. 



i 



INDEX. 



495 



Delusions, expansive, 431. 

hypochondriacal, 431. 

of persecution, 432. 
Dementia of cerebral shock, 481. 

miscellaneous, 481. 

paralytica, stupor in, 411. 

primary, 479. 

senile, see Developmental Dementias. 

terminal, 483. 
Dementias, developmental, 480. 

organic, 479. 
Desires, morbid, 437. 
Developmental dementias, 480. 
Diabetic coma, 404. 

headache, 305. 
Diathetic insanities, 457. 
Diphtheritic paralysis, 79. 
Diplopia, 321. 
Direct cerebral tracts, 47. 

pyramidal tracts, 47. 
Disease, definition of, 17. 
Disk, abnormalities of, 331. 
Disorders of consciousness, 377. 

of memory and consciousness, 357. 

of sight, 344. 

of sleep connected with acute fevers, 
390. 
Disturbances of equilibration, 194. 

of intellection, 420. 

of the special senses, 317. 

of vision, 341. 
Double consciousness, 371. 

personality, 371. 
Dynamometer, 24. 



E. 

Embolism and hemorrhage, diagnosis be- 
tween, 36. 
Embolus in vertebral artery, 31. 
Epigastric reflex, 181. 
Epilepsy, 103. 

alcoholic, 117. 

aura in, 103. 

cardiac, 111. 

convulsive stages of, 105. 

diagnosis between idiopathic and or- 
ganic, 114. 

idiopathic, 103. 

Jacksonian, 96, 112. 

organic, 112. 

pleuritic, 110. 

relations between the convulsion of 
childhood and, 109. 

spinal, 76. 
Epileptic insanity, 458. 

mania, 460. 

sleep, 396. 

vertigo, 204. 
Epileptiform convulsion, 97. 
from toxaemia, 117. 
in general paralysis, 116. 
Equilibration, disturbances of, 194. 
Erector-spinal reflex, 181. 
Erotomania, 437. 



Erythromyalgia, see Raynaud's Disease. 
Essential vertigo, 212. 
Exaltation of memory, 368. 
Exhaustion, headache of, 308. 
Expansive delusions, 431. 
External popliteal nerve, 94. 
Extremities, pains in the, 289. 
Eye, associated paralysis of, 329. 

movements of the, 318. 
Eye-strain, headaches of, 306. 



Face-pains, 312. 

Facial hemiatrophy, progressive, 249. 

nerve, 87. 

spasm, 136. 

paralysis, 39, 40. 
Failure of memory, 369. 
Fever, convulsions in, 117. 
Field of vision, 342. 

contraction of the, 353. 
Fifth nerve, 86. 
Fixed pains, 290. 
Fourth nerve, 86. 

Fulminating coma, see Coma Foudroyant. 
Functional aphasia, 363. 

paralysis, 24. 

paraplegia, 42. 



G, 

Gait, ataxic, 196. 

in cerebellar disease, 198. 
Gastric headache, 305. 

vertigo, 207. 
General anaesthesia, organic, 266. 

chorea, 148. 

paralysis, 26, 197. 

epileptiform convulsions in, 116. 
lenticular, 32. 
of the insane, 452. 
Genital crises, 298. 

hyperaesthesia, 282. 
Girdle-pain, 295. 

sensation, 65. 
Globus hystericus, 100, 120. 
Glosso-labial paralysis, 247. 
Glosso-pharyngeal nerve, 89. 
Gluteal reflex, 181. 
Goll, columns of, 47. 
Gouty anaesthesia, 267. 

insanity, 457. . 



H. 

Habit chorea, 166. 
Haematomyelitis, 49. 
Hallucination, 425. 
Headache, 301. 

alcoholic, 304. 

anaemic, 308. 

caffeinic, 305. 



496 



INDEX. 



Headache, cardiac and pulmonic, 306. 

congestive, 308. 

diabetic, 305. 

gastric, 305. 

hysterical, 308. 

lithaemic, 303. 

malarial, 303. 

nasal, 307. 

nervous, 307. 

of exhaustion, 308. 

rheumatic, 303. 

sympathetic, 306. 

toxaemic, 303. 

uraemic, 304. 
Headaches of eye-strain, 306. 
Head-pains, 301. 
Hearing, 317. 
Heat-exhaustion, 380. 
Hebephrenia, 481. 
Hemianaesthesia, bulbar, 268. 

cerebral, 270. 

from disease of pons, 268. 

from lesion of peduncle, 269. 

hysterical, 259. 

involving special senses, 271. 

organic, 267. 

spinal, 267. 

without involvement of speoial senses, 
267. 
Hemianopsia, 348. 
Hemiataxia, 162. 
Hemiopia, 348. 
Hemiplegia, 32. 

cerebral, 35. 

diagnosis between true and false, 34. 

disorder of sensation in, 39. 

from lesion in pons, 39. 

hysterical, 34. 

progressive, from lesion of pons, 42. 

spinal, 35. 

with aphasia, 39. 
Hemiplegic arthropathies, 227. 
Hemorrhage and embolism, diagnosis be- 
tween, 36. 

cerebral, convulsions from, 115. 

with spinal membranes, 49. 
Herpetic pain, 294. 
Hydrocephalic cry, 446. 
Hydrophobia, spurious, 120. 
Hyperesthesia, 281. 

genital, 282. 

hysterical, 282. 

organic, 285. 

spinal, 284. 
Hyperbulia, definition of, 421. 
Hypochondriacal delusions, 431. 
Hypnotism, 402. 

Hypo-melancholia, see Simple Melan- 
cholia. 
Hysteria, 122. 

minor, 120. 
Hysterical anaesthesia, 257. 
diagnosis of, 262. 

breast, 282. 

chorea, 159. 

contractures, 169. 



Hysterical general paralysis, 27. 

headache, 308. 

hemianaesthesia, 259. 

hemiplegia, 34. 

hyperaesthesia, 282. 

insanity, 462. 

joints, 283. 

monoplegia, 67. 

paralysis, 25. 

paraplegia, 44. 

sleep, 401. 

spasms, 134. 

vertigo, 205. 
Hysteroidal convulsion, 100. 

characteristics of, 102. 

convulsions, 120. 



Idiopathic epilepsy, 103. 

poliomyelitis, 238. 
Ilio- hypogastric nerve, 93. 
Ilio-inguinal nerve, 93. 
Imperative act, definition of, 433. 

conception, definition of, 433. 
Incomplete insanity, 4S5. 
Infantile paralysis, contractures in^ 168. 

spaf^tic, 75. 
Inferior gluteal nerve, 94. 
Infiainmations, internal, chorea in, 166. 
Inflammatory bulbar paralysis, 31. 

spasms, 134. 
Insane, general paralysis of the, 452, 
Insanities, complete, 470. 

complicating, 443. 

diathetic, 457. 

periodic, 484. 

pure, 469. 
Insanity, alcoholic, 467. 

circular, 4S4. 

complete non-periodic, 470. 

definition of, 439. 

epileptic, 458. 

gouty, 457. 

hysterical, 462. 

incomplete, 485. 

of masturbation, nrr Hebephrenia. 

of pubescence, ?re Hebephrenia. 

primary confusional, 482. 

sleep in, 404. 

syphilitic, 463. 
Insomnia, 389. 

Intellection, disturbances of, 420. 
Intercostal nerves, 93. 
Intermittent paralysis, 27. 
Internal popliteal nerve, 95. 



Jacksonian epilepsy, 96, 112. 
Jaw -jerk, 183. 
Joint atrophies, 82. 
Joints, hysterical, 283. 

trophic changes in, 227. 
Jumpers, see Miryachit. 



I 



INDEX. 



497 



K. 

Katatonia, 477. 

Kleptomania, 436. 

Knee-jerk, 183. 

constancy of, 187. 

diseases which increase, 191, 

diseases which lessen, 187. 



li. 

Landry's paralysis, 49, 51. 

lesions of, 53. 
Laryngeal crises, 299. 
Laryngismus stridulus, 131. 
Latah, see Miryachit. 
Lateral sclerosis, 67, 171. 

amyotrophic, 67. 
Lead-poisoning, 243. 
Lenticular general paralysis, 32. 
Lesions of aphasia, 364. 
Lethargy, 393. 
Lithaemic headache, 303. 
Local choreas, 160. 
paralysis, 85. 
spasms, 128. 

syncope, see Raynaud's Disease. 
Locomotor ataxia, 196. 

loss of teeth in, see Trophic Bone- 
Changes. 

pain-crises in, 295. 
Logoplegia, 360. 
Long thoracic nerve, 90. 
Loss of personal identity, 371. 



M. 



Major renal paraplegia, 44. 
Malarial headache, 303. 
Malignant multiple neuritis, 56. 
Mania, 471. 

acute, 471. 

chronic, 473. 

epileptic, 460. 

gravis, see Acute Periencephalitis. 

homicidal, 436. 

of character, 486. 

periodic, 484. 

reasoning, 485. 

suicidal, 436. 

without delirium, 485. 
Masturbation, insanity of, see Hebe- 
phrenia. 
Median nerve, 91. 
Melancholia, 475. 

agitata, 476. 

attonita, 476. 

periodic, 484. 

senile, see Developmental Dementias. 

simple, 476. 

without delirium, see Simple Melan- 
cholia. 
Melancholy with stupor, see Melancholia 
Attonita. 



Membranes, spinal, hemorrhage into, 49. 
Memory, disorders of, 357. 

exaltation of, 368. 

failure of, 369. 

general, 368. 
Meniere's disease, see Aural Vertigo. 
Meningeal rigidity, 168. 
Meningitis, 406, 443. 

cerebro-spinal, 449. 

idiopathic, diagnosis of, 448. 

tubercular, 445. 

diagnosis of, 448. 

symptoms of, 446. 

Mental deteriorations, 478. 

disorders, alcoholic, 465. 
Metallotherapy, 34, 259. 
Migraine, 309. 
Minor hysteria, 120. 
Miryachit, 177. 
Miscellaneous dementia, 481. 
Mobile pains, 290. 
Monoantesthesia, organic, 273. 
Monomania, 485. 
Monoplegia, 67. 

abrupt cerebral, 72. 

cerebral, 72. 

double, 68. 

from injury or disease of nerves, 73. 

from pressure on nerve, 73. 

hysterical, 67. 

irregularity of implication of muscles 
in, 68. 

peripheral, 73. 

progressive cerebral, 72. 

toxic, 74. 

varieties of, 68. 
Morbid desires, 437. 

impulse, definition of, 433. 

sleep, 390. 
Motor excitements, 96. 
Movements of the eye, 318. 

rotatory, 200. 
Multiple cerebro-spinal sclerosis, 144. 

neuritis, 55, 197. 
diagnosis of, 58. 
malignant, 56. 
subacute, 58. 

paralysis, 74. 
cerebral, 75. 
paraplegia from, 48. 
peripheral, 79. 

simulating general paralysis, 2S. 
syphilitic, 75. 

spinal sclerosis, 67, 146. 
Muscle, sterno-mastoid, 89. 

trapezius, 89. 
Muscles of organic life, spasms of, 128. 

trophic lesions of, 235. 

voluntary spasms of, 131. 
Muscular atrophy, progressive, 243. 

degeneration, diseases which cause, 
238. 
Musculo-cutaneous nerve, 91. 
Muscuio-gpiral nerve, 91. 
Myelitis, acute central, 53. 

chronic, 65. 



32 



498 



INDEX. 



Myelitis, subacute central, 64. 
transverse, 60. 

early diagnosis of, 62. 
Myotatic contractures, «ee Deep Reflexes, 
effects of hysteria in, 193. 



N. 



Narcolepsy, 398. 
Nasal headache, 307. 
Nelavan, 391. 
Nerve, abducens, 86. 

anterior crural, 93. 

external popliteal, 94. 

facial, 87. 

fifth, 86. 

fourth, 86. 

glosso-pharyngeal, S'.J, 

ilio-hypogastric, 93. 

ilio-inguinal, 93. 

inferior gluteal, 94. 

internal popliteal, 95. 

long thoracic, 90. 

median, 91. 

monoplegia from pressure on, 73. 

musculocutaneous, 91. 

musculo-spiral, 91. 

obturator, 93. 

peroneal, ttee External Popliteal 
Nerve. 

posterior tibial, 95. 

sciatic, 94. 

sixth, 86. 

spinal accessory, 89. 

subscapular, 90. 

superior gluteal, 94. 

trigeminus, 86. 

trochlear, 86. 

ulnar, 92. 
Nerves, anterior thoracic, 91. 

intercostal, 93. 

monoplegia from injury or disease of, 
73. 

spinal, 92. 

supra-scapular, 90. 
Nervous cough, 130. 

headache, 307. 

system, trophic changes in, 250. 

weakness, 18. 
Neuralgia of trigeminal nerve, 313. 
Neuralgic temperament, 287. 
Neurasthenia, 18. 

neuralgia in, 20. 
Neuritis, contractures of, 169. 

multiple, 55, 197. 
diagnosis of, 58. 
malignant, 56. 
subacute, 58. 

optic, 331. 

reactions of degeneration in, 59. 

trigeminal, 314. 
Neuroses, occupation, 132. 
Night-palsy, 414. 
Night-terrors, 418. 
Nocturnal hemiplegia, 414. 



Non-painful paraplegia, 51. 
Nymphomania, 437. 



O. 



Obturator nerve, 93. 
Occupation neuroses, 132. 
Ocular vertigo, 20S. 
Oculo-motor paralysis, 85, 323, 
QSsophageal spasm, 128. 
Ophthalmoplegia externa, 328. 

interna, 327. 
Optic neuritis, 331. 

papilla, atrophy of. 335. 

tract, anatomy of, 344. 
Organic amblyo|)ia, 345. 

aniusthesia, 265. 

dementias, 479. 

disease of the brain, 112. 

epilepsy, 112. 

general anaesthesia, 266. 

hemiana'sthcsia, 267. 

without involvement of special 
senses, 267. 

hyperscsthesia, 285. 

local anirsthesia, 274. 

m(>noana?sthesia, 273. 

paralysis, 2Vk 

paranaesthesia, 272. 

para}>legia. 46. 

stupor and coma, 405. 

vertigo, 203. 



P. 

Pachymeningitis, cervical, 63. 

haomorrhagica, 406. 
Pain, 286. 

crises, 295. 

fixed, 290. 

girdle, 295. 

herpetic, 294. 

in the extremities, 289. 

mobile. 290. 

of vertebral carie.«. 294. 

reflex, 288. 

trunkal, 29:.. 
Painful paraplegia, 50. 
Pains, face, 312. 

of chronic fibrous inflammation, 294. 

reflex, 293. 

rheumatic, 294, 

toxfemic, 294. 
Palmar reflex. 181. 
Paraesthesia. 285. 

major renal, 44. 

non-painful, 51. 

organic, 46. 

painful, 50. 

subacute, 60. 
Paralyses, general, 26. 
Paralysis, 23. 

agitans, 141. 

alcoholic, 27. 



4 



INDEX. 



499 



Paralysis, alcoholic spinal, 60. 

ascending, 2S, 49, 51. 

assumed, 25. 

Bell's, 87, 

bulbar general, 30. 

cerebral multiple, 75. 

chronic peripheral, 83. 

crossed, 40. 

oculo-motor, 41. 

detection of, 23. 

diphtheritic, 79. 

facial, 39, 40. 

forms of, from disease of pons, 269. 

functional, 24. 

general, 197. 

cerebral, 29. 

epileptiform convulsions in, 116. 

of the insane, 452. 

glosso-labial, 247. 

hysterical, 25. 
general, 27. 

infantile spastic, 29. 

inflammatory bulbar, 31. 

intermittent, 27. 

Landry's, 49, 51. 

lenticular general, 32. 

local, 85. 

multiple, 74. 

paraplegia from, 48. 
simulating general paralysis, 28. 

oculo-motor, 85, 323. 

of abducens nerve, 326. 

of trochlear nerve, 325. 

organic, 26. 

peripheral multiple, 79. 

pons, 29. 

pseudo-hypertrophic, 84. 

reflex, 24, 42. 

sensory, 252. 

spastic infantile, 75. 

spastic, lesions of, 78. 

syphilitic multiple, 75. 

toxaemic general, 28. 
peripheral, 82. 
Paralytic chorea, 160. 
Paramyoclonus multiplex, 166. 
Paranaesthesia, organic, 272. 
Paraphasia, 362. 
Paraplegia, 42. 

abrupt, 49. 

chronic, 65. 

from multiple paralysis, 48. 

functional, 42. 

hysterical, 44. 
Paresis, 452. 
Paretic dementia, 452. 
Parkinson's disease, 141. 
Peduncle, hemianaesthesia from lesion of, 

269. 
Peduncular tract, 38. 
Perforating ulcer, 215. 
Periencephalitis, 452. 

acute, 450. 
Periodic insanities, 484. 

mania, 484. 

melancholia, 484. 



Peripheral irritations, 107. 

monoplegia, 73. 

multiple paralysis, 79. 

nervous diseases, trophic bone- 
changes in, 225. 

paralysis, chronic, 83. 
toxa?mic, 82. 

vertigo, 206. 
Personal identity, loss of, 371. 
Personality, double, 371. 
Petit mal, 105. 
Phantom tumor, 130. 
Phrenitis, 450. 
Plantar reflex, 181. 

Pneumonia resembling meningitis, 449. 
Polioencephalitis, 412. 
Poliomyelitis, 80. 

idiopathic, 238. 
Pons, anaesthesia in lesion of, 41. 

forms of paralysis from disease of, 
269. 

hemianaesthesia from disease of, 268. 

hemiplegia from lesion in, 39. 

paralysis, 29. 

progressive hemiplegia from lesion 
of, 42. 

tumor of, 30. 
Position of clot, diagnosis of, 37. 
Posterior cerebellar artery, temporary 
arrest of circulation in, 30. 

tibial nerve, 95. 
Post-hemiplegic chorea, 161. 
Pre-hemiplegic chorea, 160. 
Primary confusional insanity, 482. 

curable dementia, see Stuporous In- 
sanity. 

dementia, 479. 
Progressive facial hemiatrophy, 249. 

muscular atrophy, 83, 243. 
Prosopalgia, 315. 
Pseudo-general paralysis, 464. 

hypertrophic paralysis, 84. 

paralysis, see Lenticular General Pa- 
ralysis. 
Psychic anaesthesia, 264. 
Psychical automatism, 177. 
Pupils, 336. 

action of, to light, 339. 

diseases in which deranged, 340. 

movements of accommodation, 339. 

mydriasis of, 339. 

myosis of, 338. 
Pure insanities, 469. 
Pyramidal tracts, 47. 
Pyromania, 436. 

R. 

Raynaud's disease, 217. 
Reaction of degeneration, 235. 
Reasoning mania, 485. 
Rectal anaesthesia, 255. 

spasm, 129. 
Reflex chorea, 152. 

pain, 288. 



500 



INDEX. 



Reflex pains, 293. 

paralyses, 24, 42. 

spasms, 134. 

trigeminal nerve pain, 313. 

unconsciousness, 397. 
Reflexes, 180. 

deep, 182. 

effects of epilepsy on, 192. 

nature of, 185. 

superficial, 180. 
Renal paraplegia, 44. 
Rheumatic headache, 303. 

pains, 294. 
Rhythmical spasms, 159. 
Rosenthal's test, 62. 
Rotatory movements, 200. 



Satyriasis, 437. 

Scapular reflex, 181. 

Sciatic nerve, 94. 

Sclerosis, amyotrophic lateral, 67. 

cerebral, 456. 

lateral, 07, 171. 

multiple cerebro-spinal, 144. 
spinal, 67,146. 
Senile tumors, 140. 

dementia, see Developmental De- 
mentias. 

melancholia, sec Developmental De- 
mentias. 
Sensation in bulbar paralysis, 31. 

modes of testing, 253. 
Sense-shock, 414. 
Sense of smell, 357. 

of taste, 355. 
Sensibility, exaltations of, 281. 
Sensory aphasia, hcc Word-Blindness. 

paralysis, 252. 

pathways, description of, 265. 
Sight, 318. 

disorders of, 344. 
Simple melancholia, 476. 
Sixth nerve, ^Q. 
Skin-diseases, 221. 
Skin pupillary reflex, 339. 
Sleep, abnormal, 391. 

accidents of, 414. 

definition of, 378. 

disorders of, connected with acute 
fevers, 390. 

epileptic, 396. 

in insanity, 404. 

its disorders and accidents, 389. 

morbid, 390. 

toxaemic, 404. 
Smell, sense of, 356. 
Somnambulism, 415. 
Spasmodic tabes, 66. 
Spasms, 96. 

apparently causeless, 135. 

cortical, 134. 

facial nerve, 136. 



Spasms, hysterical, 134. 

inflammatory, 134. 

local, 128. 

nictitating, 137. 

oesophageal, 128. 

of the muscles of organic life, 128. 

of voluntary muscles, 131. 

rectal, 129. 

reflex, 134. 

rhythmical, 160. 

spinal accessory, 138. 

urethral, 129. 
Spastic infantile paralysis, 29, 75. 

paralysis, lesions of, 78. 
Special senses, disturbances of, 317. 

hemianoesthesia involving, 271. 
vertigo from, 208. 
Spermatorrhoea, 18. 
Spinal accessory nerve, 89. 
spasm, 138. 

anaemia, 21, 62, «ec also Spinal Hy- 
peripsthesia. 

apoplexy, 49. 

arthropathies, 228. 
artificial, 234. 

cord, anatomy of, 46. 

lateral columns of, 47. 
motor fibres of, 37. 

epilepsy, 76. 

hcmianaesthesia, 267. 

hemiplegia, 35. 

hyperaesthesia, 284. 

irritation, nee Spinal AnaDmia, and 
Spinal HyperiDSthesia. 

membranes, hemorrhage into, 49. 

meningitis, chronic, 169. 

nerves, 92. 

paralysis, alcoholic, 60. 

sclerosis, multiple, 67, 146. 
Sterno-mastoid muscle, 89. 
Strabismus. 3 IS. 

diplopia from, 321. 
Stupor, definition of, 378. 
Stuporous afl'ections, non-specific, 406. 
specific, 408. 

insanity, 482. 
St. Vitus's dance, 148. 
Subacute central myelitis, 64. 

multiple neuritis, 58. 

paraplegia, 60. 
Subscapular nerve, 90. 
Sudden loss of consciousness, 379. 
Sunstroke, 380. 
Superficial reflexes, 180. 
Superior gluteal nerve, 94. 
Supra-scapular nerves, 90. 
Sympathetic headache, 306. 
Syphilitic coma, 408. 

insanity, 463. 

multiple paralysis, 75. 



Tabes, spasmodic, 66. 
Taste, sense of, 355. 



I 



INDEX. 



601 



Temperament, neuralgic, 287. 
Terminal dementia, 483. 
Testing vision, method of, 341. 
Tetanic convulsions, 102, 122. 
Tetanoid affections, differential diagnosis 

of, 125. 
Tetanus, 123. 
Tetany, 127. 

Thalamus optici, lesion of, 38. 
Thermic fever, see Sunstroke. 
Thomson's disease, 172. 
Throat, anaesthesia of, 255. 
Thrombus in vertebral artery, 31. 
Tic, 136. 

Tic-douloureux, 136, 315. 
Titubation, 198. 
cerebellar, 198. 
diagnostic value of, 199. 
Torticollis, see "Wry-Neck. 
Toxaemic amblyopia, 346. 
general paralysis, 28. 
headache, 303. 
pains, 294. 

peripheral paralysis, 82. 
sleep, 404. 
vertigo, 211. 
Toxic monoplegia, 74. 

tremors, 140. 
Tract, direct cerebral, 38. 

peduncular, 38. 
Tracts, crossed pyramidal, 47. 
direct cerebral, 47. 
pyramidal, 47. 
pyramidal, 47. 
Trance, 393. 
Transitory frenzy, 473. 
Transverse myelitis, 60. 

early diagnosis of, 62. 
Trapezius muscle, 89. 
Tremor, 97. 
Tremors, 140. 
senile, 140. 
toxic, 140. 
Trigeminal nerve, neuralgia of, 313. 
reflex pain of, 313. 
neuritis, 314. 
Trigeminus nerve, 86. 
. Trismus neonatorum, 125. 
Trochlear nerve, 86. 

paralysis of, 325. 
Trophic bone-changes, 225. 

loss of teeth from, 222. 
changes in the hair and nails, 223. 
in joints, 227. 
in the nervous system, 250. 
lesions, 213. 

acute destructive, 213. 

not accompanied by wide-spread 

destruction of tissue, 221. 
of muscles, 235. 
skin-changes, 221. 



Trunkal pains, 293. 
Tubercular meningitis, 44.). 

diagnosis of, 448. 

symptoms of, 446. 
Tumor of pons, 30. 
phantom, 130. 
Turck, columns of, 47. 
Typhomania, sec Acute] Periencephalitis. 



U. 



Ulnar nerve, 92. 

Unconsciousness from indirect causes, 385. 

from internal diseases, 386. 

from irritative poisons, 386. 

from opium, 386. 

from uraemia, 386. 

reflex, 397. 
Uraemia, 118. 
Uraemic convulsions, 118. 

headache, 304. 
Urethral spasm, 129. 



Vaginal anaesthesia, 256. 
Vertebral caries, pain of, 294. 
Vertiginous status, 201. 
Vertigo, 200. 

aural, 209. 

cardiac, 204. 

causes of, 202. 

epileptic, 204. 

essential, 212. 

from the special senses, 208. 

gastric, 207. 

hysterical, 205. 

nature of, 202. 

neurasthenic, 205. 

ocular, 208. 

organic, 203. 

peripheral, 206. 

toxemic, 211. 
Visceral anaesthesia, 255. 
Vision, contraction of the field of, 253. 

disturbances of, 341. 

field of, 342. 

method of testing, 341. 
Vomiting, 129. 



W. 

Wakefulness, abnormal, 389. 
Word-blindness, 361. 
Word-deafness, 361. 
Word-memory, 359. 
Writer's cramp, 19, 132. 
Wry-neck, 140. 



THE END. 



IMPORTANT WIEDICAL WORKS 

BY H. C. WOOD, M.D., LL.D. 



Treatise on Therapeutics. 

Comprising Materia Medica and Toxicology, with Especial Reference to 
the Application of the Physiological Action of Drugs to Clinical Med- 
icine. By H. C. T^TOOD, M.D., LL.D. Sixth Edition, Revised, with 
Important Additions, and Adapted to the New Pharmacopoeia. One 
volume. 8vo. Extra Cloth, $6.00. Library Sheep, $6.50. Half Russia, 
$7.00. 

" Altogether, this work stands by itself as the only complete treatise on the physiological action 
of drugs in the English language, and no student of scientific therapeutics should be without it." 
— London Practitioner. 

" To get fully at its great merits demands a careful perusal of every page. It should be Id the 
library of every medical man. "SVe cheerfully recommend it to the profession." — Cincimiati Lamctt 
and Clinic. 

"It is unnecessary to say to any student of materia medica thai the work of Professor Wood is 
a standard, and that, as an exposition of the physiological action of drugs and ita appUwition to 
clinical medicine, it is unsurpassed. The success of the work is well merited, and reflects credit 
upon its studious and accomplished author." — Neic York Medical Record. 

"This standard work still retains the first place among all our treatises on this subject, and 
bids fair to keep its position as the best text-book on the action of drugs." — Botton Medioal and 
Surgical Journal. 

*• In its especial field it is unequalled in any language, and no library is complete withoat it." 
— Buffalo Medical and Surgical Journal. 

"This is undoubtedly the most popular text-book on therapeutics by an American aatbor. 
1 n its present form there is no work better fitted to teach a student the essentials of materia meilica 
and therapeutics." — New York Neic Btmtdies. 



Fever. 

A study in Morbid and Normal Physiology. By H. C. WOOD, M.D., 
LL.D. Large 8vo. Extra Cloth, $2.50. 



Thermic Fever, or Sunstroke. 

By H. C. "WOOD, M.D., LL.D. Awarded the Boylston Prize of Har- 
vard University. 12mo. Extra Cloth, $1.25. 

" We know of no work which gives so full an exposition of this affection. The profeMJon are 
under many obligations to Dr. Wood for his excellent raonogruph."— Bu/a/o Medioal and Surgical 
Journal. 



*** For sale by Booksellers generally, or will be sent, transportation free, 
upon receipt of price by 

J. B. LIPPINCOTT COMPANY, Publishers, 

715 and 717 Market Street, Philadelphia. 



THE UNITED STATES 

DISPENSATORY. 



With Denison's 
Patent Index 



Fifteenth Edition. 
Illustrated. 




CAREFULLY REVTSKD J^TTD REWRITTEN BY 

HORATIO C. WOOD, M.D., LL.D., J. P. REMINGTON, Ph.G., 

AND 

S. P. SADTLER, Ph.D., F.C.S. 

Handsomely Bound in One Volume, Royal 8vo, containing 1928 pages. Price, in 

Cloth Extra, $7.00; Best Leather, Raised Bands, $8.00; 

Half Russia, Raised Bands, $9.00. 



Vor JFaoility of Reference, J>eni8on'a Patent Index will he Inserted for 
$t,00 Additional to above Prices. (See Illustration,) 



"We commend this work as a most valuable addition not only to pharmaceutical literature, 
but to the medical profession as almost invaluable. Its literature, its chemistry, and its phar- 
macy are fully up to any similar work here or abroad of its kind, and tlie high standard of excel- 
lence in the past is only enhanced by the thoroughly reliable and trustworthy work of the present 
fifteenth edition." — Pharmaceutical Record. 

"It has been the vade-mecum of every practitioner, more valued than, perhaps, any other book 
in the library. Every edition has been an improvement upon the one preceding it, and the volume 
has grown in value and scope as it has grown in bulk and popularity." — Gaillard's Medical Journal. 

"As a work of reference it has few equals and no superiors in our language, and it does great 
credit to American pharmacy and therapeutics." — Edinburgh Medical Journal. 

"The present edition sustains the high reputation of former editions." — London Practitioner. 

"It forms a valuable work of reference as well for the practitioner as for the pharmacist." — 
Dublin Journal of Medicine. 

" The book as a whole is one that is most worthy to hold a place in the pharmacist's select 
library." — London Pharmaceutical Journal. 

*^*For sale by all Medical Booksellers, or will be sent, charges prepaid, by mail or express, on 
receipt of price. 

J. B. LIPPINCOTT COiVIPANY, 

715 and 717 market St., Pliiladelptiia. 



^ 



